CHILDREN'S HOSPITAL FOUNDATION

							       CHILDREN’S HOSPITAL & RESEARCH CENTER FOUNDATION

           AUTOMATIC PAYROLL DEDUCTION AUTHORIZATION

I would like to make a charitable gift to Children’s Hospital & Research Center
Foundation. I hereby authorize CHRCO to initiate payroll deductions as specified below.
I understand that these deductions are voluntary; I may increase or decrease the amount at
any time, and it will remain in effect as specified below.


_________________________________                           ___________________
Employee Signature                                          Effective Date


_________________________________                           ___________________
Employee Name (Please print)                                Employee Number


_________________________________                           ___________________
Employee Address/City/State/Zip                             Telephone Number


Please deduct $___________ each pay period until:

                                                    My employment has ended

                                                    For one year

                                                    Other ____________


     Use my gift where needed most.

     I would like to designate my gift to:
     ___________________________

     Check here if you would like to remain anonymous.



PLEASE RETURN COMPLETED FORM TO PAYROLL DEPARTMENT AND A
COPY TO CHILDREN’S HOSPITAL & RESEARCH CENTER FOUNDATION