Donate to Power of One "*" indicates required fields Use this form to pledge a 100% tax-deductible donation.Employee Type:* Physician Advanced Practice Nurse / Physician Assistant Leader All Others I Pledge:* A Sustaining Payroll Deduction A Sustaining Monthly Gift A Payroll Deduction (through December 2024) A One-Time Contribution Hidden(Physician) I Pledge:* A Sustaining Payroll Deduction A Sustaining Monthly Gift A One-Time Payroll Deduction A One-Time Contribution Sustaining payroll deduction will begin July 2023 and recur until further notice. Future adjustments to sustaining gifts can be made by contacting the Saint Francis Foundation at 573-331-5133 or foundation@sfmc.netFuture adjustments to sustaining gifts can be made by contacting the Saint Francis Foundation at 573-331-5133 or foundation@sfmc.netPayroll deductions will begin July 2023 and end December 2024.Sorry, physicians are ineligible to donate ETO. Please choose another pledge type.Payroll Deduction Amount:* $200 Per Pay Period – Qualifies for 1875 Founders Society recognition. Benefits include: Donor Wall recognition and invitation to Major Donor Dinner. $10 Per Pay Period – Entered to win $2,400 worth of gas $5 or More Per Pay Period – Free Foundation Mug. Fill it up anytime at the Tuscan Sun for just 50 cents! $200 per pay period $150 per pay period $100 per pay period $75 per pay period $50 per pay period $40 per pay period $30 per pay period $20 per pay period $15 per pay period $10 per pay period $5 per pay period Other amount per pay period Amount to Deduct Per Pay Period:*One-Time Contribution Payment Method:*Minimum One-Time Contribution is $5 Check Cash Credit Card / Debit Card / eCheck Payroll Deduction One-Time Check / Cash Donation Amount:*Please forward your donation via mail or a Foundation drop box in the Medical Center.One-Time Credit Card / Debit Card / eCheck Donation Amount:*Credit Card donations will be processed on the next page after you’ve submitted this form.Please enter a number greater than or equal to 5.One-Time Payroll Deduction Amount:*Number of ETO Hours Pledged:* ETO will be eligible for donation beginning January 2024 through June 2024. Minimum of 8 hours. Applicable sales tax will be withheld from Earned Time Off donations. Earned Time Off will be paid out at 100%. Current ETO Sell-Back policy applies. Physicians are ineligible to donate ETO.Sustaining Gift Monthly Contribution Amount:*Credit card / debit card / eCheck only. Your payment will be processed on the next page after you’ve submitted this form.Total Monetary Contribution:I Wish to Support (Up to Four):* Area of Greatest Need CancerCare CardiacCare Caring Fund Chapel Hospice Parents with Hope Sister Esther Fund Where People Come First Fund Specify Fund Name:*Please list a Saint Francis Foundation Fund Name:* First Last Work Email Address:* Address:* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number:*Employee Department:*Select a Department:3rd Floor ACC – 6500Accounting – 8170ACO – 7299Administration – 8250Advanced Orthopedic Specialists – 7851Ambulance – 7080Anesthesia – 6700Anesthesiology – 6710Audit – 8168AWL Family Healthcare System – 7836Bio-Medical Services – 8060Black River Management – 8255BRASC – 6506Business Development – 8135Call Center – 6845Cancer Services Administration – 7310Cap Labor EMR Pre-Implementation – 6640Cape Cardiology Group – 6680Cape Care for Women – 7415Cape Cerebrovascular & Endovascular Neurosurgery – 6690Cape Diabetes & Endocrinology – 6820Cape ENT Group – 7417Cape Gastroenterology Specialists – 6865Cape Gynecologic Oncology – 6790Cape Medical Group – 7837Cape Medical Oncology – 6670Cape Neurology Specialists – 6695Cape Neurosurgical Associates – 7855Cape Pain Management – 7815Cape Pediatric Group – 7846Cape Perinatology Services – 6590Cape Physician Associates – 7825Cape Primary Care – 7835Cape Pulmonology & Sleep Medicine – 7020Cape Radiation Oncology – 7300Cape Spine and Neurosurgery – 6685Cape Thoracic & Cardiovascular Surgery – 7040Cardiac Intensive Care Unit – 6540Cardiac Rehab Services – 7240Cardiovascular Lab – 7030Case Management – 6521Cat Scanner – 7070Center for Digestive Diseases – 6860Central Supply – 6800Centralized Scheduling – 8180Centralized Telemetry – 7840CGO Prov Based – 9020Charleston Family Care – 7833Chest Pain & Stroke Centers – 7025Clinical Neurophysiology – 7000CMO Prov Based – 9010Communications – 8160Continuing Care Clinic – 7412Copper Top Pharmacy PB – 7857COVID 19 Unit – 6515COVID Infusion Center – 6516CTVS Prov Based – 9040Customer Service – 7390Cyberknife – 7330Deli Plus – 8017Dexter Fitness Plus – 7366Diabetes Education & Management – 7210Disaster Management – 6817Durable Medical Equipment – 7165Electrodiagnostic – 6950Emergency Room – 6850Employee Health – 6840Endovascular Lab – 6990Entrance 2 Convenient Care – 6856Entrance Management – 6813Environmental Services – 8110EPIC – 7890ERC – 8301ERC Northeast – 8303ERC Southwest – 8302Evaluation Unit – 6780Facilities Management – 8050Family Birthplace – 6600Farmington Physician Associates – 7844Ferguson Medical Group – 7861Ferguson Medical Group CH – 7863Ferguson Medical Group EP – 7864Ferguson Medical Group Lab – 7867Ferguson Medical Group SC – 7862Ferguson Medical Group SI – 7865Financial Planning – 8163Fiscal Services – 8165Fitness Center – 7290Fitness Plus – 7295Float Orderlies – 8200Food Service – 8010Foundation – 8220Friends Cafe – 8015General Medical – 6502Healing Arts Infusion Center – 7790Healing Arts Lab – 6920Healing Arts Urgent Care – 6859Health & Wellness Cat Scan – 6960Health Home – 7301Health Information Management – 7900Home Infusion Therapy – 7130Hospice – 7420Hospital Billing – 8190Hospitalists – 6830HR Misc Budget Dollars – 8155HRSA 93.110 – 8248HRSA 93.912 – 8247HRSA Outreach Grant – 6975Human Resources – 8150Immediate Convenient Care – 6857Immediate Convenient Care – Jackson – 7839Immediate Convenient Care Perryville – 6858Infection Prevention – 7880Information Systems – 8210Infusion Center – 7860Infusion Center Dexter – 7355Inpatient Dialysis – 6770Inpatient Occupational Therapy – 7180Inpatient Physical Therapy – 7200Inpatient Rehabilitation – 6620Inpatient Respiratory Therapy – 7150Inspire Boutique – 8225Intensivist – 6831IV Therapy – 7120Jackson Family Care – 7832Kids Plus – 7297Knee, Hip and Shoulder Clinic – 6985Kneibert Clinic – 7848Kneibert Lab – 6912Kneibert Pharmacy – 7849Laboratory – 6900Laundry and Linen – 8120Learning and Development – 8140Legal Services – 8169Level III NICU – 6610LTACH – 7500Magnetic Resonance Imaging – 7060Marketing – 8130Medical Affairs – 8245Medical Director – 7410Medical Intensive Care – 6550Medical Library – 7800Medical Office Building – 7400Mission Integration – 8240Neonatology – 6580Neurosciences – 6512Nuclear Medicine – 7250Nursery – 6660Nutrition Service – 7370NWM Behavioral Health – 7853NWM Pharmacy – 7854Occupational Medicine – 6855OP Children's Center – 6520Open MRI – 6970Operating Room – 6650Orthopaedic-Surgical – 6630Outpatient Occupational Therapy – 7190Outpatient Physical Therapy – 7260Outpatient Rehab Services – 7170Outpatient Speech Therapy – 7280Pain Center – 7810Palliative Care – 7425Patient Care Administration – 6400Patient Financial Services – 8175Patient Transport – 8235PB Condo – 6705Performance Improvement – 8020Performance Plus – 7292Pet Scanner – 7010Pharmacy – 7100Physical Therapy Dexter – 7155Physician Recruitment – 8246Physicians Alliance – 6505Physicians Park General Surgery – 7780Physicians Park Primary Care – 7842Piedmont Physician Associates – 7845Plant Operations – 8040Poplar Bluff Neurology Specialists – 7847Poplar Bluff Occupational Therapy – 7856Poplar Bluff Pediatrics – 7852Post Anesthesia Unit – 6750PPPC – Lab – 7843PPPC Audiology – 7834Print Shop – 8100Professional Billing – 7340Progressive Care Unit – 6560Psychology Services – 7270Purchasing & Receiving – 8230Quality Improvement – 7411Radiation Therapy – 7320Radiology – 7050Registration Center – 7360Rehab Administration Services – 7220Rehab Medical – 7838Reimbursed Salaries – 8030Retail Pharmacy – 7140Saint Francis Breast Care Center – 7850Saint Francis Clinic Jackson – 7841Saint Francis Outpatient Center – 7365Saint Francis Outpatient Center – Imaging – 7363Saint Francis Outpatient Center PB – 7364Same Day Surgery – 6980Security – 7910SFC PB 2nd – 7858Sikeston Imaging Center – 7866Sikeston Radiation Oncology – 7350Sleep Disorders Center – 7160Social Services – 8090SPD Reprocess – 7930Specialty Clinic – 7830Speech and Hearing – 7230Starr Training – 8300Sterile Processing – 7920STF Regional Lab – 6910Surgical – 6510Surgical Trauma Intensive Care – 6530The Healthy Weigh – 7298Tobacco Cessation – 7872Transfer Center – 6812Trauma – 6810Trauma Surgery Physicians – 6815Ultrasound – 7090Utilization Review – 6835Vein Center – 6760Volunteers – 8080Weight Loss Solutions – 6720Wellness – 7870Worksite Tobacco – 7873Wound Care – 7820Saint Francis Colleague Badge Number:*Pledge Agreement:* I agree to fulfill my pledge in its entirety captchaNameThis field is for validation purposes and should be left unchanged.
