Lee Memorial Health Systems

RX Games Registration

Get in the game for a better Lee Memorial Health System! Make a pledge and support your TEAM today!

   

2015 RX GAMES Funds:
 

I would like my gift to benefit one of the following (please check One box):

Cape Coral Hospital
Gulf Coast Medical Center
HealthPark Medical Center
Lee Memorial Hospital
Lee Physician Group
Outpatient Services
Golisano Children's Hospital

 


Gifts Through Employee Payroll Deduction
I authorize Lee Memorial Health System Foundation to deduct the following amount from my pay, beginning
July 2015.
 

   $1 / per pay period = $26.00
   $2 / per pay period = $52.00
   $5 / per pay period = $130.00*
   $10 / per pay period = $260.00
   $20 / per pay period = $520.00
  
$50 / per pay period = $1,300.00
  
$100 / per pay period = $2,600.00
  
$150 / per pay period = $3,900.00

One time gift of $ through payroll deduction.

I request that my RX Games payroll deduction remain in effect indefinitely.**


*Giving at this level enters you in Super Grand Prize Drawing!

**Employee may notify payroll at any time to terminate the automatic payroll deduction.
.

Donor Name:
(skip this box if you would like to remain anonymous)

First:

Last:

Street Address:

Address 2:

City:

State:

Zip Code:

Email:

Employee ID#:

Department:

Campus:

Date:



My gift is:

 

Name of Person:

Please notify:

  Name:

  Address:

  City:

  State:

  Zip:

   
   

Important: Please do not submit credit card information through this non-secure form.

If you would like to make a one-time donation through credit card or check, or if you have any questions, please call Duane Higgins at 239-343-6078 or email at Duane.Higgins@LeeMemorial.org.

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