Regions Hospital Foundation | 640 Jackson Street | Mail Stop 11202C | St. Paul, MN 55101-2595

Regions Hospital Foundation - Payroll Deduction Donation Form
Thank you for supporting our employee giving campaign. Your gift will make a world of difference for our patients, families, colleagues and community members.

Reminder to sustainers: Please do NOT complete a new payroll deduction form. Please watch your email for your annual opportunity to review and make changes for your gift.

This form is for payroll deduction donations only. Please click here if you would like to give via credit card.

Required fields are marked with *

Enter Your Contact Information
Your gift is fully tax-deductible in accordance with current tax laws. No goods or services were provided in exchange for your gift. For tax purposes, please refer to your year-end pay summary on employee self-service. If you need help, please email one@healthpartners.com.

By entering my initials below, I authorize that these donations be taken out of my paycheck beginning in September 2019. I understand that if I sign up to be a sustaining donor, my gift will be continued until I request a change.

HealthPartners
Regions Hospital
Title:
*State:
Give Your Way - Choose the areas you want to supportPlease enter the amount you’d like to give to the following areas, then they will be added together for your total gift:Foundations and Clinics
Give Your Way - Choose the areas you want to support

Please enter the amount you’d like to give to the following areas, then they will be added together for your total gift:

Foundations and Clinics
* How would you like to contribute (please choose one):
How would you like to contribute (please choose one):
*Sign me up to be a sustaining donor! What does it mean to be a sustaining donor? Sustaining gifts are made via payroll deduction and will continue each pay period until you request a change. You will receive an annual opportunity to increase, decrease, discontinue or reallocate your gift. It’s that simple!
*Sign me up to be a sustaining donor! 
What does it mean to be a sustaining donor? Sustaining gifts are made via payroll deduction and will continue each pay period until you request a change. You will receive an annual opportunity to increase, decrease, discontinue or reallocate your gift. It’s that simple!
Initials
If you have any comments or notes regarding your gift, please write them here: