W.H.A.T. Club Registration

W.H.A.T. Club Registration

W.H.A.T. Club represents the TriState Health employees who donate annually to the TriState Health Foundation. Those employees set an example for the community by pledging their own support and encouraging the community to do the same.
I give TriState Health authorization to deduct the following amount on an annual basis: (please check the box below that coincides with your donation, then specify the amount to be given)
Type of Donation*

Dollars per pay periodYearly one-time donation on the 1st pay period in JanuaryPaid Time Off (PTO) hours
If donating per pay period, below is how much your donation equivilatent to for 1 year (or 26 pay periods)
- $2 = $52
- $4 = $104
- $5 = $130
- $10 = $260
- $15 = $390
- $20 = $520
- $25 = $650
- $30 = $780
- $35 = $910
- $40 = $1,040
- $45 = $1,170
- $50 = $1,300
2. Please specify the amount of dollars per pay period, one time donation, or hours of paid time off that you wish to donate:*

3. I would like my donations to support these fund(s):*

4. Would you like to keep your donation anonymous?*

YesNo
Name*

First NameLast Name
Employee EE #:*
Email*
example@tsmh.org
Phone Number*
Department*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By clicking submit you are authorizing TriState Health to deduct your choice of either a specified amount dollars per pay period, a one-time donation the first pay period in January, or a specified amount of paid time off hours. The information that you are authorizing is outlined in this form above.
1. Type of Donation:*

Dollars per pay periodYearly one time donation on the 1st pay period in JanuaryPaid time off hours
4. Would you like to keep your donation anonymous?*

YesNo
Should be Empty: