As an employee of Rowan Regional Medical Center, you can support the hospital or Foundation events with a tax-deductible contribution through payroll deduction or a donation of accrued PTO.

Please complete the following form and return to: Rowan Regional Medical Center Foundation, 130 Mocksville Avenue, Salisbury, NC 28144, use internal mail system or FAX to 704-210-6885.

NAME: ____________________________________   Employee ID#:_______________

Department ID #:_____________ Department Name: ___________________________

Home Address: __________________________________________________________

City: ________________________________ State:____  Zip:_____________________

Home Phone: _________________________  Work Extension: ___________________

I Pledge a Total of $________ in support of ___________________________________ OR    

___Annual Giving Program

___Hospice House

___RRMC Christmas Project

___EEF Employee Emergency Fund

OR to pay for ___# of tickets to the ___Patron's Ball  ___ Campbell Classic Golf Tournament

(If gift is used for admission to any event, acknowledgement letter will reflect tax-deductible gift amount, not total amount.)

5 Deduct $_______ ONE TIME ONLY Deduction from my Bi-Weekly Pay

5 Deduct $_______ over a Total Number of ______ pay-periods to complete my pledge

5 I wish to donate ______ hours of PTO (minimum of 8 hours)

(Income taxes will be deducted from your total PTO donation. Your acknowledgement letter will reflect the converted net donation amount.)

Signature: __________________________________________ Date: __________________

Should you have any questions, please contact Vivian Connor at the Foundation office at 704-210-6880.