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Ascension Associate Giving Campaign
Workplace Campaign Pledge Form (Ascension Foundation)
STEP 1: MY INFORMATION
First Name
*
Last Name
*
Date of Birth
*
Home Address
*
Home Address
Home Address
Home Address
City
City
State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
ZIP Code
ZIP Code
Phone Number
*
Phone Type
*
Cell
Home
Work
Email Address
*
Email Type
*
Personal
Work
Ascension Location
*
Calumet
Mercy
St. Elizabeth
AMG
Job Type
*
Associate
Leader
Provider
Employee ID
*
Department
*
I am an employee of:
R1
MedXcel
Touchpoint
TriMedx
STEP 2: MY PLEDGE
PAYROLL DEDUCTION is available to Ascension Associates only.
(If you are an employee of R1, MedXcel, Touchpoint or TriMedX please choose from check or bill me options below.)
I authorize Ascension to deduct my pledge per pay period or as chosen below (payroll deduction period is February - December 2021):
Investment Options
*
Please select one option
Payroll Deduction: Per Pay Period
Payroll Deduction: One-Time Only
Credit Card
Check
Bill Me
Per Paycheck Amount x 23 Pay Periods
*
$12
$25
$50
$110
$220
Other Amount
Other Amount
= Total Amount
*
One Time Payroll Deduction Amount
*
Please contact me for my credit card information
Check Amount
*
Check Number
*
Check Date
*
Please make checks payable to the foundation in which you are donating. Write separate checks if donating to multiple entities.
Send me a pledge reminder in January 2021 for the following amount:
*
STEP 3: MY GIFT DESIGNATION
Please choose up to 3 funding options below:
Fund Choice #1
Please select one
MERCY 71102-501300 - Priority Hospital Projects Fund (Greatest Need)
MERCY 71102-501100 - AMG South Clinics Fund
MERCY 71102-503351 Behavioral Health Fund
MERCY 71102-503101 Cancer Fund
MERCY 71102-503401 Children's Health Fund
MERCY 71102-206400 Fitness for the Physically Challenged Program (includes PEACE Program)
MERCY 71102-508401 Heart and Lung Fund
MERCY 71102-513350 Needs of the Poor and Underserved Fund
MERCY 71102-521100 The Oasis Hair Studio Fund
MERCY 71102-518301 Physical and Cardiac Rehabilitation Fund
MERCY 71102-501200 Project SEARCH Fund
MERCY 71102-518200 Reach Out and Read Fund
MERCY 71102-518302 Staying Alive Cardiac Campaign
MERCY 71102-523801 Women's and Children's Services Fund
ST. E. 71101-51621 Priority Hospital Projects Fund (Greatest Need)
ST. E. 71101-50125 AMG Appleton/Fox Valley & Calumet Clinics Fund
ST. E. 71101-50308 Ascension Calumet Hospital Fund
ST. E. 71101-50570 Associate Basic Needs Fund
ST. E. 71101-50310 Cancer Fund
ST. E. 71101-51938 Child and Adolescent Behavioral Health Fund
ST. E. 71101-51623 Community Benefit Fund
ST. E. 71101-20690 Flannigan Fund for OR & ER
ST. E. 71101-21550 Grant Richman Random Acts of Kindness (Calumet)
ST. E. 71101-50830 Heart & Lung Center and Rehabilitation Fund
ST. E. 71101-50840 Joy Hair Studio Fund
ST. E. 71101-50890 Needs of the Poor and Underserved Fund
ST. E. 71101-51900 Nursing Education Fund
ST. E. 71101-EF51620 Project SEARCH Fund
ST. E. 71101-51935 SEH Adult Behavioral Health Fund
ST. E. 71101-51850 St. Elizabeth Hospital Clinics Reach Out & Read Fund
ST. E. 71101-52380 Women and Families Fund
Other
Fund Choice #1
Fund Choice #1 Amount - Designation total must match total pledge
*
Fund Choice #2
Please select one
MERCY 71102-501300 - Priority Hospital Projects Fund (Greatest Need)
MERCY 71102-501100 - AMG South Clinics Fund
MERCY 71102-503351 Behavioral Health Fund
MERCY 71102-503101 Cancer Fund
MERCY 71102-503401 Children's Health Fund
MERCY 71102-206400 Fitness for the Physically Challenged Program (includes PEACE Program)
MERCY 71102-508401 Heart and Lung Fund
MERCY 71102-513350 Needs of the Poor and Underserved Fund
MERCY 71102-521100 The Oasis Hair Studio Fund
MERCY 71102-518301 Physical and Cardiac Rehabilitation Fund
MERCY 71102-501200 Project SEARCH Fund
MERCY 71102-518200 Reach Out and Read Fund
MERCY 71102-518302 Staying Alive Cardiac Campaign
MERCY 71102-523801 Women's and Children's Services Fund
ST. E. 71101-51621 Priority Hospital Projects Fund (Greatest Need)
ST. E. 71101-50125 AMG Appleton/Fox Valley & Calumet Clinics Fund
ST. E. 71101-50308 Ascension Calumet Hospital Fund
ST. E. 71101-50570 Associate Basic Needs Fund
ST. E. 71101-50310 Cancer Fund
ST. E. 71101-51938 Child and Adolescent Behavioral Health Fund
ST. E. 71101-51623 Community Benefit Fund
ST. E. 71101-20690 Flannigan Fund for OR & ER
ST. E. 71101-21550 Grant Richman Random Acts of Kindness (Calumet)
ST. E. 71101-50830 Heart & Lung Center and Rehabilitation Fund
ST. E. 71101-50840 Joy Hair Studio Fund
ST. E. 71101-50890 Needs of the Poor and Underserved Fund
ST. E. 71101-51900 Nursing Education Fund
ST. E. 71101-51620 Project SEARCH Fund
ST. E. 71101-51935 SEH Adult Behavioral Health Fund
ST. E. 71101-51850 St. Elizabeth Hospital Clinics Reach Out & Read Fund
ST. E. 71101-52380 Women and Families Fund
Other
Fund Choice #2
Fund Choice #2 Amount - Designation total must match total pledge
*
Fund Choice #3
Please select one
MERCY 71102-501300 - Priority Hospital Projects Fund (Greatest Need)
MERCY 71102-501100 - AMG South Clinics Fund
MERCY 71102-503351 Behavioral Health Fund
MERCY 71102-503101 Cancer Fund
MERCY 71102-503401 Children's Health Fund
MERCY 71102-206400 Fitness for the Physically Challenged Program (includes PEACE Program)
MERCY 71102-508401 Heart and Lung Fund
MERCY 71102-513350 Needs of the Poor and Underserved Fund
MERCY 71102-521100 The Oasis Hair Studio Fund
MERCY 71102-518301 Physical and Cardiac Rehabilitation Fund
MERCY 71102-501200 Project SEARCH Fund
MERCY 71102-518200 Reach Out and Read Fund
MERCY 71102-518302 Staying Alive Cardiac Campaign
MERCY 71102-523801 Women's and Children's Services Fund
ST. E. 71101-51621 Priority Hospital Projects Fund (Greatest Need)
ST. E. 71101-50125 AMG Appleton/Fox Valley & Calumet Clinics Fund
ST. E. 71101-50308 Ascension Calumet Hospital Fund
ST. E. 71101-50570 Associate Basic Needs Fund
ST. E. 71101-50310 Cancer Fund
ST. E. 71101-51938 Child and Adolescent Behavioral Health Fund
ST. E. 71101-51623 Community Benefit Fund
ST. E. 71101-20690 Flannigan Fund for OR & ER
ST. E. 71101-21550 Grant Richman Random Acts of Kindness (Calumet)
ST. E. 71101-50830 Heart & Lung Center and Rehabilitation Fund
ST. E. 71101-50840 Joy Hair Studio Fund
ST. E. 71101-50890 Needs of the Poor and Underserved Fund
ST. E. 71101-51900 Nursing Education Fund
ST. E. 71101-51620 Project SEARCH Fund
ST. E. 71101-51935 SEH Adult Behavioral Health Fund
ST. E. 71101-51850 St. Elizabeth Hospital Clinics Reach out & Read Fund
ST. E. 71101-52380 Women and Families Fund
Other
Fund Choice #3
Fund Choice #3 Amount - Designation total must match total pledge
*
TOTAL ASCENSION PLEDGE/GIFT
*
Total Ascension pledge/gift amount must equal total pledge amount in 'Step 2: My Pledge'.
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