Employee Wellness Pledge Form - Maskwa Medical Center

Employee Wellness
Pledge Form

Donor Information

Name to be Acknowledged(Required)

Contact Person(Required)

First Last Title

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Contact Phone(Required)

Contact Email(Required)

Employee Wellness Donation Details

Number of Employees(Required)

Please enter a number greater than or equal to 1.

x $170 =

Number of Dependents

Please enter a number greater than or equal to 0.

x $170 =

Total Employee Wellness Contribution(Required)

Donation Details

One Time Donation of

Repeating Donation of

Every

Quarter

Year

Starting Date

# of Years

Please enter a number greater than or equal to 0.

Please apply my donation to:

Building Capital Fund

General Fund

Additionally

Please acknowledge my donation publicly

I would like to receive a tax receipt

I would like to receive news and updates about the Maskwa Medical Center

To support the Maskwa Medical Center, I/we, the undersigned donor(s), enter into this charitable contribution agreement on the [DAY] day of [MONTH], [YEAR]

Donor Signature