Casual for Cause

Thank you for supporting AR Gould's Casual for a Cause Program. To make a gift through payroll deduction, complete the fields below.

PLEASE NOTE: Your payroll deduction will begin on the next pay date after processing. By completing this form, your donation (amount per period) will be deducted from your paycheck for a total of 26 pay periods. To make your gift over a different time period, use the form enclosed in your mailing or contact Northern Light Health Foundation at 973-5055 or foundation@northernlight.org.

To make a pledge paid by credit card in installments or to make a gift of stock or for more information, contact Northern Light Health Foundation at 207.973.5055 or foundation@northernlight.org.

AR Gould Casual for a Cause Payroll Deduction

Please enter the information below.

First Name:

Last Name:

Address:

City:

State:

Zip:

Contact Phone:

Preferred Contact Email:

Employee Number:

Donation Designation:

I am aware that participation in Casual for a Cause requires that I continue to financially support the program at a cost of $2 per pay period for a total of $52 annually. This support allows me to participate in the every other Friday casual day (always the Friday after "pay day"). Should I choose to end my financial support, I will at the same time, end my eligibility to participate. I am aware that taking part in Casual for a Cause allows me to dress down if appropriate for my area but that I must still adhere to dress guidelines, including for example, no clothing with holes, no flip-flops, etc.

My typed name below constitutes my electronic signature confirming my agreement to participate in Casual for a Cause as indicated within this enrollment form.

Consent Signature:

Verification:

Enter security code:

Northern Light AR Gould Hospital

Northern Light AR Gould Hospital

Casual for Cause

AR Gould Casual for a Cause Payroll Deduction