HEALTHCARE HEROES DONATION FORM

You can apply on this page to support the employee driven Healthcare Heroes program.
To find out more about the program, visit this link.

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Healthcare Heroes Donation Form

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Acknowledgment (Optional)

Layout

In Memory Of:

In Honor Of:

Send Acknowledgment of Donation to

First

Last

Address (copy)

Address Line 1

City

State

Zip Code

Payroll Deduction

$ Deduction Amount Per Pay Period

I would like to donate every pay period (minimum $1.00 per pay period - enter $ in whole numbers)

Employee ID Number

Department

Authorization

I hereby authorize the Controller of San Mateo County to deduct my donation from my earnings each bi-weekly pay period. This authorization shall remain in effect until change is given by written notice from the employee to Controller's office.

Donor Recognition (Optional)

I would like to be listed in the contribution list
Please do not publish my name on the contribution list

Custom Captcha

San Mateo County Health Foundation, incorporated in 1989, is a public 501(c)(3) organization dedicated to supporting San Mateo Medical Center and county clinics.

San Mateo County Health Foundation is a 501(c)(3) Tax ID #94-3116070

650.573.2655

info@smchf.org

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Healthcare Heros Form

HEALTHCARE HEROES DONATION FORM

Healthcare Heroes Donation Form

Acknowledgment (Optional)

Payroll Deduction

Cause to Donate

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