Donation Form

Per Paycheck Gift
Thank you for participating in the employee giving program. Every dollar of your gift stays local and is an investment in our community.
Amount:	Per Paycheck $5.00 Per Paycheck $10.00 Per Paycheck $20.00 Per Paycheck $25.00 Per Paycheck $50.00 Other Amount $     *
I would like to support:	Greatest Need fund Cancer Center Good Samaritan (patient assistance) Scholarships Cardiac Care Campaign Breast Cancer fund Chaplaincy Fund Diabetic Education Fund Family Birth Center Healthy Youth Fund Herring House Fund Home Health Fund Imaging Fund Intensive Care Unit Fund Jan Erickson Life Saver fund Patient Rooms Fund Providence Medical Group fund Population Health Promotores de Salud Reflection Garden Fund Rehabilitation Trauma Center/ER Department Fund