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Thank you for your generosity and support of the Florida Hospital Foundation!

The Foundation and its donor campaign funds benefit our Mission of Extending the Healing Ministry of Christ and help us to provide new equipment, new growth through construction, and reach more people in need in our communities and the mission outreach areas we serve.

Please complete the required form fields below and indicate your payment choices.

Donor Information
Please complete the fields below. Your address may be used to send you a giving statement for your taxes in the coming year.

First and Last Name*

Mailing Address*

Home/Cell Phone Number*

FHHD Department Name/Number:*

Select Payment Plan Option
Please choose between a one-time deduction or a reoccuring payment plan option, and indicate which Foundation fund your monetary gift will be dedicated to.

Payroll Deduction Options*
Start New Reoccuring Donation (deducted once per pay period)
Renew my pledge from previous year (continue same amount, deducted once per pay period)
I would like to make a one-time donation through payroll deduction

Donation Dollar Amount
Minimum annual contribution is $26 (or $1 per pay period).

I would like to begin a donation of $___ per pay period, until such time as I inform payroll otherwise.

I would like to continue my pledge of $___ per pay period, the same as last year's contribution until I inform payroll otherwise.

I would like to make a one-time donation of $___, to be payroll deducted.

Indicate Fund(s) Your Gift Will Benefit
Type a number between 0 and 100 indicating the percent of your donation that should be dedicated to each Foundation fund option.

Example:

FHHD Caring Heart Employee Assistance Fund: 0%
FHHD Foundation: 0%
FHHD Dominican Republic Missions Fund: 75%
United Way: 25%

Caring Heart Assistance Fund:

Florida Hospital Foundation/Capital Equipment Fund:

Dominican Republic Missions Fund:

Donation to the United Way:

Please type your name as you wish it to appear in publications recognizing all donors.

I wish to remain anonymous

Donor Authorization
I understand that my gift will be processed according to my wishes. I am making this donation as a charitable contribution and am not receiving any goods or services in return. This is a tax-deductable gift.

I authorize the Foundation at Florida Hospital to process this request.

Your Email Address (receive a confirmation of this request)

Also send me a copy

Submit

* Required