Employee Information (please print)
Name(as you would like it to appear for recognition purposes):Home Address:
City: / State: / Zip:
Daytime Phone:
Work Location: / ALMH / Other:
Title: / Department:
- Giving Options: (please check only one)
PAYROLL DEDUCTION– INSTALLMENTS
(Due to administrative costs, there is a minimum of $3.00 per pay period)
I wish to contribute $ / per pay period. I understand that this will be paid in
26 equal installments beginning with the first pay period of the new year. My total gift
will be $ / (26 X amount deducted each pay period.)
PAYROLL DEDUCTION - ONE TIME GIFT / ONE TIME CASH GIFT (CHECK)
I wish to make a one-time contribution of / Enclosed is my check / cash in the
$ / through payroll deduction. / amount of$ / Please make
This contribution will be deducted from / checks payable to La Grange Memorial
the first pay period of the new year. / Hospital Foundation.
- I want my donation distributed as follows:
$ / Patient CareCenter Fund (your gift will be matched dollar per dollar by
CommunityMemorial Foundation – 2013 is the final year funding will qualify).
$ / ALMH Care ‘N Share Fund
$ / Other Fund:
3. I would like my gift included as part of the following Employee Tribute Fund:
4. Signature:(SEE INSTRUCTIONS ON BACK)
There are just 4 easy steps to completing your
Employee Giving Campaign pledge form…
Step #1…
Choose which giving option works best for you. There are three easy ways to make your donation: payroll deduction installments, one-time payroll deduction, or one time cash gift.
Step #2…
Select the amount of your gift and a designated area of need. Undesignated gifts will be directed to the Patient Care Center Fund.
Payroll Deduction Pledge Guide
$ 3 x 26 pay periods = $ 78 per year
$ 4 x 26 pay periods = $104 per year
$ 6 x 26 pay periods = $156 per year
$8 x 26 pay periods = $208 per year
$10 x 26 pay periods = $260 per year
$15 x 26 pay periods = $390 per year
$20 x 26 pay periods = $520 per year
$25 x 26 pay periods = $650 per year
$38.46 per pay period = $1000 per year (President’s Circle)
Areas Of Need
Patient Care Center Fund (Gifts matched dollar per dollar)
ALMH Care-N-Share Fund
Oncology Services Fund
Emergency Services Fund
Cardiology Services Fund
Women’s & Children’s Services Fund
Cardiac Rehab Services Fund
ConfiCare Program Fund
Ford Nursing Scholarship Awards Fund
Gastroenterology Fund
Inpatient Rehab Fund
Intensive Care Unit Fund
Interventional Radiology Fund
Laboratory Services Fund
Library Fund
Pastoral Care Fund
Paulson Rehab Willowbrook
Pharmacy Fund
Physical Therapy Fund
Pulmonary Rehab Fund
Radiology Services Fund
Surgical Services Fund
Wound Care Center
Volunteer Services Fund
Step #3…
Choose a Tribute Fund to designate your gift in honor/memory of a special employee. See your supervisor for more information.
Step #4…
Sign the bottom of your pledge sheet.
For additional information, call (708)245-2904
Thank you for caring!