NMHS EXECUTIVE LEADERSHIP COMMITMENT FORM

Name *

First

Last

Address *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email *

Employee # *

T-shirt Size to be worn on Fridays *

• S
• M
• L
• XL
• XXL
• XXXL

I hereby authorize Human Resources to deduct the following amount from each paycheck. This authorization will continue unless otherwise specified by me in writing.

• $50 per Pay Period
• $100 per Pay Period
• Other $ per Pay Period

If Other $ was selected - please include how much you would like deducted per pay period

In addition to the above, I would like to give the following amount each pay period to support my teammates through the Employee Assistance Fund. For More info Visit https://nmhsfoundation.org/employee-assistance/

• $1
• $2
• $10
• Other $ per Pay Period

If Other $ for Employee Assistance Fund was selected - please include how much you would like deducted per pay period.

Employee StatusFull TimePart TimeOn Call

Gifts to the Health Care Foundation of North Mississippi help people. Whether your gift goes to purchase new equipment, improve facilities, offer new programs or provide assistance to our patients, it’s all about providing better health care for the people of our region. Your gift to ONE of the following programs or facilities will touch people and help provide for theirArea of Greatest NeedNMMC - ClinicsNMMC - EuropaNMMC - Gilmore/AmoryNMMC - HamiltonNMMC - IukaNMMC - PontotocNMMC - TupeloNMMC - West PointNMMC - UnrestrictedBaldwyn Nursing FacilityBehavioral HealthBreast Care CenterCamp Blue BirdCancer CareCommunity CampaignCommunity OutreachDawson's DreamDiabetesDigestive Health CenterDr. Hiroji Noguchi Memorial ScholarshipEddie's FundFamily Residency CenterFood Services Education ScholarshipGreg Pitts ScholarshipHeart and Vascular InstituteHome HealthHOPE Physician’s FundHospiceJim Spruiell Memorial Scholarship FundJim Weldon Memorial FundNICUNursing ServicesOutpatient ServicesPastoral CarePaul Hamblin ScholarshipPharmacy RadiologyRehabRetinaRosemary Bryan ScholarshipSocial WorkWellness CenterWomens Hospital

Electronic Signature (initials) *

Date *

Name

Submit to the Health Care Foundation