W.H.A.T. Club Registration

W.H.A.T. Club Registration
I give Tri-State Memorial Hospital & Medical Campus 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 period One time donation on the 1st pay period in January Paid time off 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
- $42 = $1,092
- $45 = $1,170
- $50 = $1,300
Please specify the amount of dollars per pay period, one time donation, or hours of paid time off that you wish to donate:
Would you like to keep your donation anonymous?

Yes No
Name

First Name Last Name
Department:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
By clicking submit you are authorizing Tri-State Memorial Hospital & Medical campus to deduct your chose 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.
Should be Empty: