Icon graphics representing hospitals and giving. Text reads "Taking care of each other. Employee Giving Campaign"

Employee Giving Form

Employees can use the below form to sign up for payroll deduction gifts (one-time or recurring) or Paid Time Off (PTO) hours. Please note that if you are donating PTO hours, you must have a minimum of 80 hours in your PTO bank.

Other giving options:
- Credit card donation >
- Cash or Check - Send to the Foundation Office

Questions or need help? Please contact Les Lungren at 805-994-5419 or via email.

Questions that require an answer are marked with  *
   
* First Name
   
   
* Last Name
   
   
* Employee #
   
   
* Address
   
   
* City
   
   
* Zip
   
   
* Department
   
   
* Phone Type
   
   
* Phone Number
   
   
* Email
   
   
* Levels of Giving
   
   
Must be a full-time or part-time employee.

Your gift will be automatically calculated for you.
   
   
1 SELECT ONE: Automatic Payroll Deduction Amount (minimum $1) per pay period
   
Other:
   
REQUIRED: One-Time Payroll Deduction Amount (minimum of $10)
   
   
PTO Donation - Semi-Annually (Must have minimum 80hrs in PTO account)
   
   
PTO Donation - One-Time (Must have minimum 80hrs in PTO account)
   
   
* I want my gift to support:
   
   
Recurring Gift
   
   
* Signature (type your name in the box below)
   
   
* Today's Date
   
 Choose a date
   
* By Checking ‘I Accept’ you are agreeing to all terms and conditions that have been provided.