2016-2017 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.

If you have any questions, contact us at 412-692-3900 or gifts@chp.edu.

Title:

First Name:*

Last Name:*

Address Line 1:*

Address Line 2:

City:*

State:*

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*

Gift Designation:

(Optional) This gift is made

In Honor of

In Memory of

On the Occasion of

Please send a letter of notification to:

Address:

City:

State:

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:

2016-2017 Professional Staff Campaign Payroll Deduction Form

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