Middlesex Health Employee Giving Campaign

Please complete the form below to make your donation to the 2023 Employee + Volunteer Giving Campaign.

All fields are required unless otherwise noted.

Your Information

I am a(n)
Indicate if you are an employee or a volunteer.
Your first name is required.
Your last name is required.
A valid phone number is required.
A valid email address is required.
A confirmation email will be sent to this email address.
Please provide your employee number.
Please provide your department.

Your Gift to Middlesex Health

Continue my gift/pledge shown below every year until I change or cancel it. I understand that I will be recognized and receive thank you gifts annually but will not receive a pledge form. To provide ongoing support for Middlesex Health, I'd like to become a Sustaining Donor. I understand that my credit card will be charged monthly for the amount chosen below until I change or cancel my pledge.
Level
Please select your support level.
The minimum donation amount is $5.00. If you wish to make a gift of another amount, please call our office at 860-358-6200.
You must indicate how much you'd like to give each pay period.
Set this value to the amount you would like deducted per payroll period (26 times per year).
You must choose a subscription plan.
A donation area is required.
I wish to designate my gift to the following.
Since you have designated your donation to "Other", please provide further details.

Recognition

Please indicate how you'd like to be recognized.

Dedication

Dedication Type
A dedication type is required.
Honoree's Name is required.
Full Name
Address
City, State Zip/Postal Code

Payment Details

Accepted cards
Invalid credit card number.
Expiration Date is required.
mm/yyyy
A valid security code number is required.
Card Verification Value (CVV)
Your billing address is required.
Your billing city is required.
Your billing state/province is required.
Your billing state/province is required.
Billing Zip/Postal code is required.
Your billing country is required.