Payroll Deduction Contribution Form

"*" indicates required fields

Employee Name*
Please include your mailing address so a tax-exempt donation letter may be sent. NOTE: Using MCH’s address is not permitted.
Address*

Please select anonymous below if you would prefer not to be listed
Anonymous: Please do not list my name for public recognition.
Which Funds would you like to support?*
Please select one
Make my Gift to MCH through payroll deduction.*
Payroll Deductions will begin the second pay period in April and will continue for 26 pay periods.
Thank you for your pledge through payroll deduction! In appreciation of your gift, we would like to offer you an MCH sweatshirt. Please indicate yes or no if you would like to receive a sweatshirt. If “yes” – the Philanthropy Team will get it to you by the end of the Employee Giving Campaign.
sweatshirt
Sweatshirt Selection
Honor / Memory
Consent*
If you would like to make a one-time gift: Please make checks payable to MCH Employee Giving Campaign and send them to the Philanthropy Department or visit Donate Online Now - Monadnock Community Hospital to make a gift with a credit card. If you have questions, please call LeeAnn Moore at x1700.