Generosity Champions Membership

AdventHealth Logo in color

Generosity Champions Membership Form

Blue heart with green outline and green, light blue, and white dots inside.

Name*

First Name

Last Name

OPID*

Gender*

Date of Birth*

Preferred Email*

Address*

Address Line 1

City

State

ZIP Code

Location of Employment*

Benefit Choice*

Angel Fund Healthcare Education Strategic Priorities

Benefit Choice*

Caring and Sharing Pedestrian Bridge Strategic Priorities

Benefit Choice*

Capital Campaign H.O.P.E Pastoral Care and Nursing Excellence Strategic Priorities

I authorize ongoing payroll deduction of the amount indicated as my gift to the employee giving program at AdventHealth. I understand that I can modify, upgrade,downgrade or cancel my membership in the program at any time. If the project I've indicated reaches the point of being completely funded, my gifts will continue to benefit that area for its strategic priorities. Gifts to the employee giving program at AdventHealth are tax deductible within the IRS regulations.*

I have read the terms and conditions and have agreed & acknowledge

Signature*

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Use your mouse or finger to draw your signature above

You will be emailed a copy of this information for your records.