2018-2019 Professional Staff Campaign Payroll Deduction Form Please note that donor will be responsible for contacting Children's Hospital of Pittsburgh Foundation to stop donation. Otherwise, donation will renew on a yearly basis. Medical Staff Payroll FormDetailsIf you have any questions, contact us at 412-692-3900 or gifts@chp.edu.*Title: <Select> Dr. Mr. Mrs. Miss *First Name:*Last Name:*Address Line 1:*Address Line 2:*City:*State: <Select> Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming *Zip:*Phone:*Email Address:*Employee ID:*Employee Cost Center/Department:*$ Amount to be deducted per pay:*Please stop my donations after 12 months.*Total Amount of your gift:*Payroll <Select> UPMC Payroll CCP Payroll UPP Payroll *Gift Designation: <Select> Children's Hospital Fund Adolescent Medicine (OTR) Anesthesiology (OTR) Asthma & Allergy (OTR) Audiology and Speech (OTR) Basil J. Zitelli, MD Fund (DRG OTR) Cardiology (OTR) Child Advocacy (OTR) Critical Care (OTR) Cystic Fibrosis (OTR) Dermatology (OTR) Down Syndrome Center Fund (OTR) Emergency Services (OTR) Endocrinology (OTR) Gasto Motility (OTR) Gastroenterology (OTR) Genetics (OTR) Hearing Center (OTR) Hematology & Oncology (OTR) IBD Center (OTR) Infant Stroke Program (OTR) Infectious Disease (OTR) Nephrology (OTR) Neurology (OTR) Neurooncology (OTR) Neurosurgery (OTR) Newborn Medicine (OTR) Orthopaedics (OTR) Pediatric Diabetes (OTR) Pediatric General Surgery (OTR) Pediatric Otolaryngology (OTR) Plastic Surgery (OTR) Primary Care Center (OTR) program for NFRD (OTR) Sickle Cell (OTR) Trauma (OTR) Urology (OTR) <Enter your own value> *Enter your own value*(Optional) This gift is made In Honor of In Memory of On the Occasion of *of*Please send a letter of notification to:*Address:*City:*State: <Select> Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming *Zip:*Relationship of the person above to person honored/remembered:*Please include the following message in the letter: *Name as you would like it to appear in donor listings:*I prefer to make this donation anonymously:*Comments: *