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 15 P