Prisma Health Baptist Easley Hospital Employee Payroll Deduction Authorization Form

Please complete this form to authorize payroll deductions. Anticipated start of deductions will be the first pay period of the new fiscal year in October 2023.

This year the Miracle Team Campaign will be raising money for the “greatest needs” of Prisma Health Baptist Easley Hospital. These funds will be used to assist with the needs of hospital departments that were not able to be included in the capital budget.

For more information, please contact Candi Forester-Smith, Foundation Manager, by phone at 864-442-7617 or by email at Candi.Forester-Smith@prismahealth.org.

Baptist Easley Employee Payroll Deduction Authorization Form

Personal Information

Name

First

Last

Address *

Address

Street Address

Street Address 2

City

State/Province

Zip/Postal

Email Address *

Phone Number *

Work Information

Employee Number *

Department Name *

Hospital/Dept Number

Donation Information

What would you like your donation to go towards?

Patient Care Fund

Project Search

Donation amount per period

$.00

Would you like your donation to be a one time deduction or a full year of deductions?

One time payroll deduction

Full year payroll deduction

Signature

Enter your full name to sign this form *

Date *

Captcha

If you are human, leave this field blank.