Partners Pledge Form - Rochester General Hospital Foundation

PARTNERS
Giving Society
ROCHESTER REGIONAL HEALTH SYSTEM
FOUNDATIONS
Partners Giving Society recognizes donors who support the Rochester Regional Health System
with an unrestricted annual gift of $1,000 or more.
MEMBERSHIP LEVELS:
Member $1,000 – $2,499
Patron
$2,500 – $4,999
Benefactor
$5,000+
I wish to support Rochester Regional Health System with a gift of $________________ each year for ______ year(s).
I would like to designate my gift to support (check all that apply)
___ Newark-Wayne Community Hospital Foundation
___ Rochester General Hospital Foundation
___ Unity Health Foundation
Name (please print)______________________________________________________________________ Email_____________________________________
Signature_ ___________________________________________________________________________ Date_______________________________________
This is a joint gift Spouse/Partner______________________________________________________________________________
Please print your name(s) as you wish to be listed in Honor Rolls:
______________________________________________________________________________________________________________
Payment Information
Frequency: n Annually n Monthly n Quarterly
I/We prefer
not to be
listed in print
Honor Rolls
n Please send me a reminder in the month of _______________
n Enclosed is a check in the amount of $________________________
Please make checks payable to the foundation checked above.
n Please charge my first payment of $_________________ to my credit card n One-time n Recurring
n Visa n MasterCard n Discover n AmEx Card #______________________________________________________________________ Exp. Date______________
Name (as it appears on card)______________________________________________ Signature_________________________________________________ n I prefer to give online - visit giveRRHS.org
n Payroll deduction (RRHS staff only) _Employee ID#________________________
I authorize the following to be deducted from my paycheck each pay period.
Per pay period $_ ________________________________________________________ Start date_____________ End date_______________
Signature____________________________________________________________________________________________ Date ___________________
n My gifts will be matched by ______________________________________ (Please include your company’s matching gift form)
Newark-Wayne Community Hospital Foundation
Rochester General Hospital Foundation
Unity Health Foundation
Rochester Regional Health System Foundations – 100 Kings Highway S., Suite 2300 Rochester, NY 14617
giveRRHS.org – 585.922.4800
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