Employee Giving Form

First Name Last Name

Address

City/State/Zip

Home Phone Cell Phone

Email CHR Location/Department

My Total Annual Gift $

Method of Payment:

Check (Please make checks payable to CHR)
Payroll Deduction
$ per paycheck for # of pay periods
Credit Card/Online - Click Here
Cash

By checking this box and typing my name and date below, I am electronically signing my pledge form
Yes Date:
Please keep my donation confidential

For more information or questions regarding the 2022 employee giving campaign please contact
Katie Reaves at kreaves@chrhealth.org or 860-697-3381

**Please email your pledge form to Katie Reaves at kreaves@chrhealth.org.**
**Checks can be mailed to the Windsor Main Office**