2012-13 Caregiver Campaign: PeaceHealth Ketchikan Medical Center (Payroll Deduction Donation)

Form Description

PeaceHealth Foundations: Caregiver Giving Campaign Logo

Use the form below to make a Payroll Deduction to PeaceHealth Ketchikan Medical Center Foundation. All gifts are tax-deductible as allowed by law. Thank you for your generous support!

To donate by credit card, use this form.

To donate using cash or check, download and print this form.


Fill in the information below. Use the scroll bar on the right to move down the page. When finished, click the Save button located at the bottom of the form.

Questions marked with a red * require a response.

Home Mailing Address
PeaceHealth Information

I would like my gift to be a tribute:
Please acknowledge my gift to the honoree or the family of the person being remembered:

One-Time Payroll Deduction Donation
Will come out of the first pay period in January
Recurring Payroll Deduction Donation

I understand that the above amount per pay period will be deducted from each paycheck until I instruct the foundation otherwise.

PTO Donation
Minimum of 4 hours

Are you close to your maximum allowable accrual of 420 PTO hours? Turn some into cash for the Medical Center’s programs and departments! You must have twice your status hours still available after your PTO donation; contact Payroll to verify. PTO donations aren’t tax-deductible, and will occur the 1st pay period in January, or the one following our receipt of this form after January.

How you want your gift used

Please select one of the giving options below
By selecting this box, I/we AUTHORIZE the hospital to use my/our gift to enhance excellence in areas deemed most appropriate.

By selecting this box, I/we RESTRICT the hospital to use my/our gift to purchase technology and equipment of my/our choosing, as indicated below, from the campaign’s official “Table of Needs”.

By selecting this box, I/we DIRECT my/our gift to the hospital’s endowment fund, to ensure a reliable source of long-term funding is available to meet the FUTURE needs of the hospital.

By selecting this box, I/we RESTRICT the hospital to use my/our gift to purchase PANDA WARMERS for the New Beginnings Birth Center

Final Confirmation

Thank you for supporting the 2012-13 Caregiver Campaign.
Click Save to submit your form.

If you would like a copy of this completed form, please enter your email address.