2025 DMF Colleague Giving Form

2025 DMF Colleague Giving Form

Colleagues can make a one-time or recurring gift using payroll deduct or credit/debit card. PTO donations are one-time and must be given in 8 hour increments.

Donation Method*

Payroll Deduction

PTO

Credit/Debit Card

Colleague Information

First Name*

Last Name*

Colleague ID*

Your Colleague ID is your colleague number found on your badge (no initials, only numbers)

Email*

Phone *

Phone

Address Line 1*

City*

State*

Zip*

Your Department Name*

Donation Information/Method

Payroll Terms*

One Time

Per Pay (26 pay periods; June 2025 - May 2026)

Continual Per Pay (Will renew automatically each year)

One-Time Donation Amount

One-time donations have a $5 minimum.

Use dollar values $0.00

Per Pay Donation Amount

Per-pay pledges must be at least $1.

Use dollar values $0.00

PTO Donation

As a PTO donor, I understand that:

My PTO donation must be in eight-hour increments.
My entire PTO donation will be withdrawn at my current rate of pay at the time of processing.
I must have 40 hours PTO remaining after the donation is withdrawn. If I do not, my donation will be reduced in eight-hour increments to leave me with no less than 40 hours PTO.
Once it is withdrawn, my PTO donation is irrevocable.
My PTO donation has no effect on my accrued sick leave, nor may I donate any accrued sick leave.
My donation to the Foundation will be net of tax and pension withholding.
My net donation is tax deductible to the fullest extent permitted by federal and state tax law.

PTO Hours*

Must be in 8 hour increments

Please use my donation for*

Where the need is greatest

Healthcare Career Education

Colleague Emergency Assistance

Pay by Credit or Debit Card

Click HERE to enter your card information

Authorization*

I acknowledge and agree that I am donating to the DMH Foundation and am authorizing a payroll and/or PTO deduction in the amount provided above.

Send me a copy of my responses

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