Employees That Care Application

McLaren Port Huron Foundation|Documents and Links|Employees That Care Application

Note: Fields marked with an * indicates required field

Employee Name: *

Employee Number: *

Department: *

Address: *

Address 2:

City: *

State: *

Zip Code: *

Work Phone: *

Home Phone: *

Email: *

Name as you would like it to appear for recognition purposes: *

Contribution Type: *

New Contribution

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Donation Information

I authorize McLaren Port Huron to deduct the following amount through payroll deduction: *

$10 per pay period*

$5 per pay period*

$4 per pay period*

$3 per pay period*

$2 per pay period*

$1 per pay period*

* If your pledge to the ETC Club totals at least $100 per year, you will also become a member of the Cornerstone Club of McLaren Port Huron Foundation. Cornerstone Club recognition (you can include spouse's name below)

Name of Spouse: *

If you wish to make a lump sum gift instead of a payroll deduction, you may use your credit card below. If using check or cash, please print this form once complete and attach your check or cash and either take it to the Foundation Office, or call the Foundation Office and a staff member will pick it up.

Single Gift Amount: *

$

Please contact me for credit card payment information: *

Yes

No

By submitting this form, I certify that I am an(a): Employee at McLaren Port Huron and either (1) desire to have the amount indicated deducted from my paycheck per pay period or (2) to have the amount indicated charged to my credit card.

Get in Touch
Foundation Hours
- Mon - Fri: 8:00am - 4:30pm
  Sat - Sun: Closed
1201 Stone Street, Suite 11
Port Huron, MI 48060
Phone: (810) 989-3776

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