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Schneck Medical Center: JCUW Annual Campaign 2021-2022

Schneck Medical Center: Online Giving

First Name *

Last Name *

Department *

Phone *

Please include an email address for an emailed receipt.

Birth Date

Street Address

City

State

Postal Code

Leadership Giving

Booster $1,000

Merit $1,500

Pacesetter $3,000

Jackson Society $5,000

National Tocqueville Society $10,000+

Please choose the amount per pay period you would like to give to help the community!

I want to contribute the following amount per pay period *

$5
$10
$15
$25
$50
Fair Share (one hour's pay per month)
Same Donation Amount Last Year
Other

Pay Periods *

Weekly (52 payments)

Biweekly (26 payments)

Monthly (12 payments)

Fair Share Amount

If you have selected fair share (one hours pay per month) please list your hourly pay.

Other Amount

Please include all notes/comments regarding your gift that you would like United Way to know.

Comments

Credit Card Information

If you would like to give a one time donation with a debit/credit card, please include the card number, expiration date, and code on the back.

Electronic Signature

PO Box 94
113 N Chestnut, Ste 305
Seymour, IN 47274
812-522-5450