Colleague Giving Donation Form

The Office of Philanthropy is proud to provide support to our Hospitals and our community and we’re inspired by the impact that we can have – together. Thank you for your support of Mercy Medical Center and your consideration of a gift to this Campaign.

Step 1: Colleague Information

Name *

Address *

Address 2

City *

State *

Zip *

Phone *

Email *

Colleague ID # *

Department

Step 2: Designation

AREA OF GREATEST NEED HEALTHCARE FOR THE HOMELESS COLLEAGUE CRISIS FUND NURSING EDUCATION ANDY YEE PALLIATIVE CARE UNIT COLLEAGUE CARE FUND OTHER	Employer *
I want my gift to honor a colleague
Name	Department

Step 3: Contribution (Please select one)

1. Payroll Deduction
I wish to contribute via PAYROLL DEDUCTION I authorize my PAYROLL DEDUCTION of $ per Pay Check (every two weeks). I wish to change my current PAYROLL DEDUCTION as of to $ per Pay Check (every two weeks). I authorize a onetime PAYROLL DEDUCTION of $.

2. Check Donation
I wish to contribute by Check Donation Check Donation of ($) Make checks payable to Mercy Medical Center and send to: Mercy Medical Center Office of Philanthropy, Gift Processing Center, PO Box 320635, Hartford, CT 06132-9900

3. Cash Donation
I wish to contribute by Cash Donation Cash Donation of ($) For cash donations, please email funddevelopment@sphs.com for information.

Step 4: Appreciation Gift

Gifts of $100 or more receive a hospital-specific "Be Inspired" long-sleeve men or ladies t-shirt. (while supplies last)

T-Shirt Size

I am interested in including the hospital in my will or life insurance. Please contact me.
I wish to remain anonymous on any publication of donors.