Employee Campaign Form

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The Tuality Healthcare Foundation supports OHSU Tuality Healthcare by funding projects and programs that enrich the patient experience and wellness of our community. Thank you for making a gift through payroll deduction.

Please complete the information below. Questions? Contact 503-681-1170.

With a donation of $40 or more per pay period, you will receive Reserved Parking.

I wish to donate the following per pay period:*

$2
$5
$10
$20
$30
$40
$50
$100
$200

Other:

Please equally distribute my donation to the following fund(s) (no less than $1 per fund when equally distributed, please):*

Greatest Need
Mobile Mammography
Employee Scholarships
¡Salud! Services
General Cancer Fund
Cancer Care Fund
Community Education
Baker Memorial Healing Garden
Diabetes Education
Geriatric Psychiatry
Heart/Cardiac Rehab
High School Scholarships
Home Health
Kidney Care
Library
Maternity/Pediatric
Spiritual Outreach

Employee number:*

Department:*

Last four digits of SSN:*

I would like to remain anonymous:

Yes

I understand that all previously submitted employee campaign forms are void and this donation will be considered most current. I understand that my donation is continuous and that I may cancel or make changes to the gift amount or fund designation at any time:*

YesNo

Contact Information

Company:

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Work Phone:

Email:*

Fields marked * require an entry.

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