2015 Annual Employee Giving Appeal

Office use only $ _______ rate/pay period x ____ pay periods = $ ________

Angel FundThe Angel Fund provides patients and families financial support and comfort beyond medical needs. Patients being treated at Marshfield Clinic can receive assistance for necessities such as: transportation, groceries, clothing, utilities, shelter, supervised care, and medical expenses.

Project Shine Grant FundThe Project Shine Grant Fund allows employees to invest in the mission of Marshfield Clinic by funding employee-driven projects that directly improve the quality of care for our patients. Each year, employees have the opportunity to apply for funding from the Project Shine Grant Fund to receive support for program or department needs such as: equipment needs, educational resources for patients, and program support.

Pediatric NeedsThe Pediatric Needs fund supports patient comfort, education and other needs for children seen in the Central division. This fund also provides support for pediatric subspecialists doing outreach throughout the Marshfield Clinic system. Gifts to this fund provide distraction and comfort items, small equipment, and patient resource materials. The Pediatric Needs fund helps providers and staff show exceptional care to the children they serve.

General Medical ResearchResearchers at the Marshfield Clinic Research Foundation are working on ground-breaking projects every day. Gifts to the General Medical Research Fund help fund innovative projects that follow a rigorous scientific review process. These general research studies are important as they fuel the growth of research and discovery. Support from this fund is available to physicians and scientists who are studying a wide variety of diseases and disorders.

Employee informationName ______________________________________________________ Employee # ____________________

Center _______________________________ Dept ______________________ Routing loc _______________

My spouse should also receive recognition as an employee donor. Name ________________________________

Designating your giftIf no fund is selected, gifts will be designated to the Project Shine Grant Fund. If more than one fund is selected, gifts will be split evenly between selected funds.

l Angel Fund l Project Shine Grant Fund l Pediatric Needs l General Medical Research

l Other ____________________________________________________________________________________

Additional areas to support may be found at www.marshfieldclinic.org/funds

Donation informationRecurring gift through payroll deduction

l Hour Club (one hour of my wage per pay period)

l $________ per pay period NOTE: There are 24 pay periods in each campaign year.

Payroll deductions will begin July 2015 and continue through June 2016 unless the option below is selected.

l Ongoing payroll deduction (Will continue until you notify Development)

One time gift I would like to make a one-time gift of $ ______ ____

l One-time payroll contribution (taken out of the first pay period in July 2015)

l Cash

l Check (payable to Marshfield Clinic)

Credit Card: l Visa l American Express l Discover l MasterCard

Name _______________________________________

Card # ______________________ Exp date _______

- OR -

Gift authorizationSignature _____________________________________________________________ Date _______________

Other gift information

This gift is: l In memory of l In honor of Name _____________________________________________

Person to notify _____________________________ Relationship to honoree __________________________

Address ___________________________________________________________________________________

Please send me information on: l ways I can get involved with Project Shine. l opportunities to become a philanthropic leader at Marshfield Clinic.

l including Marshfield Clinic in my will or trust. l designating a portion of my retirement plan to Marshfield Clinic.

What does my gift to Project Shine support?Your gift will help Marshfield Clinic continue to shine in its mission to serve all patients through accessible, high quality healthcare, research, and education. Contributing to Project Shine allows you to make a difference above and beyond the work you do every day.

Your gift can support any area of our mission you find meaningful. The highlighted funds below are only a sample of all the ways you can support Marshfield Clinic. For a complete list of funds visit www.marshfieldclinic.org/funds.

Route pledge forms to Development, 1R1. To make a credit card or payroll gift online, visit http://srdweb1/clinic/dept/development/