MedStar Georgetown University Hospital Associate Giving Campaign:
Giving – The Power to Heal

2014 Gift Commitment

Pledge Form


                          Yes! I would like to support MedStar Georgetown University Hospital's mission to save and change lives!  

* required information

Donor Information
First Name* Middle Initial Last Name*
  Note: Please use your legal name as it appears on your badge.
PeopleSoft ID/Employee #* Department Name*
  Note: If your entity has made the conversion to PeopleSoft you must include your new ID number to complete your gift.
City* State*     Zip* 
- -
Phone (Work) - -
Pledge Information
Please select your contributions below by indicating the amount you would like deducted from each paycheck.

Please note: A minimum contribution of $4.00 per pay is required. If you are interested in giving a gift that is less than $4.00 per pay, please call 202-444-0721. All payroll deduction pledge payments begin January 3, 2014 and will occur for the 26 pay periods in 2014. If you have fewer than 26 pay periods, please use the print version of this form.
Please designate per pay amount. You may contribute to more than one entity
(FOR REFERENCE: $4/pay = $104 annual gift; $15/pay = $390 annual gift; $25/pay = $650; $50/pay = $1,300 annual gift)
$ /pay:  MedStar Georgetown University Hospital $ /pay: MedStar Montgomery Medical Center
$ /pay:  MedStar Health Research Institute $ /pay: MedStar National Rehabilitation Network
$ /pay:  MedStar Visiting Nurse Association $ /pay: MedStar St. Mary's Hospital
$ /pay:  MedStar Southern Maryland Hospital Center $ /pay: MedStar Franklin Square Medical Center
$ /pay:  MedStar Union Memorial Hospital $ /pay: MedStar Good Samaritan Hospital
$ /pay:  MedStar Washington Hospital Center $ /pay: MedStar Harbor Hospital
$ /pay:  MedStar Health
MedStar Associate: Do not type into the "per-pay deduction" area below. Your yearly pledge amount will be calculated for you automatically based on your designations listed above.
Per-pay deduction $ X 26 pays for a total deduction/gift of $

I acknowledge that by checking this box and typing my name and date, I authorize MedStar Georgetown University Hospital to deduct this gift from my pay as a charitable contribution for the year of 2014.
(Note: Deduction line on paystub will say “Donation.”)
Date / / (MM/DD/YYYY)
Acknowledgement Information Information

For recognition purposes, please note exactly how you would like your name to appear:

I wish to have my gift remain anonymous.

Please print this completed form for your records. We will also send you a receipt for tax purposes.