Icon graphics representing hospitals and giving. Text reads "Giving Together, Working Together"

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 Candace Brown 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.
   
   
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
   
 Today's Date
   
* By Checking ‘I Accept’ you are agreeing to all terms and conditions that have been provided.