Select the program you would like to support at any Omaha and Council Bluffs campus.  Each of us can make a difference with our gift, no matter the amount, and together we can transform our communities.  Thank you for the work you do each day and your gift supporting CHI Health.

Omaha Metro & Council Bluffs Employee Campaign

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**Please note** Deductions must be a minimum of $5. If you select more than one fund, you must contribute at least $5 per fund, per deduction. Your total donation will be divided equally between all funds selected.
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Please choose your gift options below.
By Payroll Deduction
Please deduct the following amount (per pay period, or one time only, as noted below), starting January 3, 2020.

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By PTO Deduction
Please deduct one or more hours of PTO (per pay period, or one time only, as noted below), starting January 3, 2020. *Note* PTO donations can be made in half hour increments.
**NOTE** The gross value of donated PTO hours will be forwarded to the foundation. The employee will pay taxes on the gift.

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Be a member of the Hour Club
Please deduct the equivalent of an hour or more of my pay (per pay period, or one time only, as noted below), starting January 3, 2020. *Note* Hour Club donations can be made in half hour increments.

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I would like my gift to support:
Please select the area/program you would like your gift to support.

Digital Signature
Entering my full name below indicates I authorize CHI Health to withhold my payroll deduction as indicated above. Payroll deductions will continue indefinitely, until I notify the Foundation to stop. I understand that the information on this form will be entered into the Foundation database and used to administer this donation, send acknowledgements and tax statements, etc.
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