Employee Wellness Pledge Form - Maskwa Medical Center

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Maskwa Healthcare

Funding & Sponsorship

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

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

Donation Details

One Time Donation of

Repeating Donation of

Every

Quarter

Year

Starting Date

MM slash DD slash YYYY

# 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

Payment Method(Required)

Cheque

EFT to donation@maskwamedical.ca

Credit Card via NAF

Please send a cheque payment to:
Maskwa Medical Center
722042B RR63
Clairmont, AB
T8X 4L7

Please pay via Credit Card through Northwestern Alberta Foundation Donation Form

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Maskwa Medical Center is proud to operate on Treaty 8 Territory, Traditional Lands of First Nations and Métis people.

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About Us

How We Started
Values
Who We Are
Our Indigenous Connection

How We Started
Values
Who We Are
Our Indigenous Connection

Contact Info

Phone: 780-831-0796
kdrysdale@maskwamedical.ca

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