Patient Assistance Fund

Patient Assistance Fund

Donation & Pre-Order Form
Name

First NameLast Name
Ivinson Email
example@example.com
Ivinson Department
Phone Number or Extension
Please enter a valid phone number.Format: (000) 000-0000.
Fun Top Friday Donation (includes a fun themed scrub top, a fun Ivinson-branded shirt, or jeans)
T-Shirt Order Deadline

The deadline to order a t-shirt is Monday, September 14. Please know there may be additional orders, but it is not gaurenteed.
Patient Assistance Swag (Please note, we have limited shirt sizes available, some sizes may need to be ordered)
T-Shirt Size (all adult unisex sizing, Comfort Colors brand. Please note, we have limited shirt sizes available, some sizes may need to be ordered)
Additional Donation to Patient Assistance Fund
Payroll Deduction Authorization

Please complete the form below to authorize the full amount of your donation and pre-order to be deducted from your Ivinson paycheck(s). Thank you!
Total Amount (enter total dollar amount of all selections made above)
How many pay periods would you like to divide your payments across?
Enter "1" for full payment to be deducted from a single paycheck
I hereby authorize Ivinson Memorial Hospital to deduct the above total payment(s) from my paycheck, and transmit the amount(s) to the Ivinson Memorial Hospital Foundation.
Signature
If you have questions or prefer to pay by cash, check, or credit card, please contact the IMH Foundation Office at (307) 755-4520 or foundation@ivinsonhospital.org
Thank you!

We sincerely appreciate your donation to the Patient Assistance Fund and your support of the IMH Foundation!
Should be Empty:

T-Shirt Order Deadline

Payroll Deduction Authorization

If you have questions or prefer to pay by cash, check, or credit card, please contact the IMH Foundation Office at (307) 755-4520 or foundation@ivinsonhospital.org

Thank you!