Centerstone Employee Giving Campaign

Payroll Deduction
Credit Card
Evergreen

"*" indicates required fields

Step 1 of 2

50%

NAME (as listed with HR):*

First Name Last Name

EMAIL FOR CONFIRMATION:*

CENTERSTONE STAFF ID (available in Workday):*

HOW I WOULD LIKE TO BE RECOGNIZED (if different than NAME above, i.e. Robert vs Bob or adding spouse name):

ADDITIONAL OPTIONS:

I prefer my gift be recognized as "Anonymous"

I AM BASED/LOCATED IN THIS STATE (click and choose one):*

My base/location state:

DURATION AND GIFT AMOUNT OF PAYROLL DEDUCTIONS (click duration then select an amount). All deductions begin the next available paycheck.*

One time deduction (Next Payroll Cycle)

$25

$50

$100

$250

$500

Other

Other Amount:

AMOUNT TO BE DONATED PER PAYCHECK - Choose the amount you wish to donate per paycheck (your annual gift total is shown).

$2 per paycheck ($52 per year)

$5 per paycheck ($130 per year)

$10 per paycheck ($260 per year)

$15 per paycheck ($390 per year)

$20 per paycheck ($520 per year)

$25 per paycheck ($650 per year)

$50 per paycheck ($1300 per year)

$75 per paycheck ($1950 per year)

$100 per paycheck ($2600 per year)

Other

Other Amount Per Pay

WHERE I WOULD LIKE MY DONATION TO BE USED (click and choose one):*

Changing Lives Together Fund (Area of Greatest Need)

Anywhere at Centerstone

Florida

Illinois

Indiana

Military Services

Tennessee

Capital Campaign

Capital Campaign - Unrestricted

Capital Campaign - Military Services - National Veterans Counseling Fund

Capital Campaign - Military Services - Cohen Clinics - Unrestricted

Capital Campaign - Military Services - Cohen Clinic - Clarksville

Capital Campaign - Military Services - Cohen Clinic - Fayetteville

Capital Campaign - Military Services - Cohen Clinic - Hinesville

Capital Campaign - Military Services - Cohen Clinic - Jacksonville

Capital Campaign - Institute - Simulation Training Center

CARES Fund (direct client assistance)

Anywhere at Centerstone

Florida

Illinois

Indiana

Tennessee

Military Services

National Veterans Counseling Fund

Cohen Military Family Clinic - Clarksville, TN

Cohen Military Family Clinic - Fayetteville, NC

Cohen Military Family Clinic - Hinesville, GA

Cohen Military Family Clinic - Jacksonville, FL

Endowment

The A John Rose Endowment Fund

The Barry S. Hale Endowment Fund

The Bonnie Brackett Endowment Fund

The Brad Smith Endowment Fund

The Carol Zwick Endowment Fund

The Chris Julian Fralish Endowment Fund

The Colleen Thayer Endowment Fund

The Dana Oman Endowment Fund

The David J. Emmert Endowment Fund

The David Melby, PhD, Endowment Fund

The Deborah Taylor Tate Endowment Fund

The Dede Wallace Fund (supports services in TN - Davidson and contiguous counties) - *R

The Doug Leonard Endowment Fund

The Dr. Raghu Upender Endowment Fund

The Dr. Stephen J. Pritchard Endowment Fund

The Duke Legacy Endowment Fund (Florida Services)

The Ella P. Hayes Fund (supports services in TN) - *R

The Geoff McKim Endowment Fund

The George Bullard Stadler Endowment Fund

The George Spain Research Fund (supports behavioral health research) - *R

The Jack Wallace Endowment Fund

The James E. Sweeten Endowment Fund

The Janet Ayers Endowment Fund

The Jennifer Embree Endowment Fund

The Jennifer L. Bencie, MD Endowment Fund

The Joan C. Sivley Endowment Fund

The Jonathan Morphett Endowment Fund

The Joseph E. Roche Endowment Fund

The Josie Seybold Endowment Fund

The Kelly Crockett Endowment Fund

The Lee Ann Summers Ingram Endowment Fund

The Lee Brackett Endowment Fund

The Lieutenant General (Retired) Hubert G. Smith Endowment Fund

The Linda Trader Endowment Fund

The Lisa Hooker Campbell Endowment Fund

The Mark Faulkner Endowment Fund

The Michael J. McCalip Endowment Fund

The Mike Enos Endowment Fund

The Philip D. Krebs Endowment Fund

The Philippa M. Guthrie Endowment Fund

The R. Parker Griffith Endowment Fund

The Reed Farley Endowment Fund

The Reverend Bob Phillips Endowment Fund

The Reverend James T. Golden Endowment Fund

The Richard D. Sivley Fund (A) (supports children and youth services in TN - Davidson and contiguous counties) - *R

The Richard D. Sivley Fund (B) (supports children and youth services in TN) - *R

The Richard H. Fitzgerald Endowment Fund

The Sally Sheahan Endowment Fund

The Steven C. Holman Endowment Fund

The Steven E. Bryant Endowment Fund

The Terrye Davidson Endowment Fund

The Thomas W. (Tom) Mahler, Jr. Endowment Fund

The Timothy A. Knowles Endowment Fund

The Tom Johnson Endowment Fund

Other Restriction (state/program)

Thank you for making a difference in our clients' lives by giving!

Name

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

Step 1 of 3

33%

NAME (as listed with HR):*

First Name Last Name

Email*

CENTERSTONE STAFF ID (available in Workday):*

HOW I WOULD LIKE TO BE RECOGNIZED (if different than NAME above, i.e. Robert vs Bob):

ADDITIONAL OPTIONS:

I prefer my donation be recognized as "Anonymous"

I AM BASED/LOCATED IN THIS STATE:

My base/location state:

I WOULD LIKE TO GIVE (click and choose one):**

$25

$50

$100

$250

$500

Other

Other - Amount

Total

WHERE I WOULD LIKE MY DONATION TO BE USED (click and choose one):*

CARES Fund (direct client assistance)

Changing Lives Together Fund (Area of Greatest Need)

Military Services

Capital Campaign

Endowment

Other Restriction (state/program)

Billing Address*

Street City State Zip Code

Mailing Address

Same as Billing Address

Street City State ZIP Code

Tax Receipt Options

Electronic only - emails as entered above.

Electronic with paper copy mailed

Payment Method*

Help by Covering Transaction Fees?

Yes, I'll help.

Payment Processing Fees

Price: $0.00

Payment Processing Fees

Price: $0.00

Total

Payment Method

MasterCard

Visa

Supported Credit Cards: MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

Card Type

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Card Expiration Date Month Year

CVV Code Cardholder Name

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

Step 1 of 2

50%

NAME (as listed with HR):*

First Name Last Name

EMAIL FOR CONFIRMATION:*

CENTERSTONE STAFF ID (Available in Workday):*

HOW I WOULD LIKE TO BE RECOGNIZED (if different than NAME above, i.e. Robert vs Bob):

ADDITIONAL OPTIONS:

I prefer my gift be recognized as "Anonymous"

I AM BASED/LOCATED IN THIS STATE:*

Florida

Illinois

Indiana

Tennessee

Other

My Base/Location State

I WISH TO...*

Increase my Evergreen donation

Begin a new Evergreen donation

Decrease my Evergreen donation

Discontinue my Evergreen donation

Choose the amount you wish to donate each paycheck and we will calculate your annual gift total.

$2 per paycheck ($52 per year)

$5 per paycheck ($130 per year)

$10 per paycheck ($260 per year)

$15 per paycheck ($390 per year)

$20 per paycheck ($520 per year)

$25 per paycheck ($650 per year)

$50 per paycheck ($1300 per year)

$75 per paycheck ($1950 per year)

$100 per paycheck ($2600 per year)

Other per paycheck

One Time Donation - deducted first paycheck in January

Choose the ADDITIONAL amount you would like to add to your current Evergreen deduction.

$2 per paycheck ($52 per year)

$5 per paycheck ($130 per year)

$10 per paycheck ($260 per year)

$15 per paycheck ($390 per year)

$20 per paycheck ($520 per year)

$25 per paycheck ($650 per year)

$50 per paycheck ($1300 per year)

$75 per paycheck ($1950 per year)

$100 per paycheck ($2600 per year)

Other per paycheck

One Time Donation - deducted first paycheck in January

Choose the amount you wish decrease each paycheck and we will calculate your annual gift total.

$2 per paycheck ($52 per year)

$5 per paycheck ($130 per year)

$10 per paycheck ($260 per year)

$15 per paycheck ($390 per year)

$20 per paycheck ($520 per year)

$25 per paycheck ($650 per year)

$50 per paycheck ($1300 per year)

$75 per paycheck ($1950 per year)

$100 per paycheck ($2600 per year)

Other per paycheck

One Time Donation - deducted first paycheck in January

Other Amount Per Paycheck

Other Amount One Time Annually

WHERE I WOULD LIKE MY DONATION TO BE USED (click and choose one):*

To help us serve our staff better, your feedback about why you are discontinuing your gift would be helpful

Changing Lives Together Fund (Area of Greatest Need)

Anywhere at Centerstone

Florida

Illinois

Indiana

Military Services

Tennessee

CARES Fund (direct client assistance)

Anywhere at Centerstone

Florida

Illinois

Indiana

Tennessee

Military Services

National Veterans Counseling Fund

Cohen Military Family Clinics - Clarksville, TN

Cohen Military Family Clinics - Fayetteville, NC

Cohen Military Family Clinics - Hinesville, GA

Cohen Military Family Clinics - Jacksonville, FL

Capital Campaign

Capital Campaign - Unrestricted

Capital Campaign - Military Services - National Veterans Counseling Fund

Capital Campaign - Military Services - Cohen Clinics - Unrestricted

Capital Campaign - Military Services - Cohen Clinic - Clarksville

Capital Campaign - Military Services - Cohen Clinic - Fayetteville

Capital Campaign - Military Services - Cohen Clinic - Hinesville

Capital Campaign - Military Services - Cohen Clinic - Jacksonville

Capital Campaign - Institute - Simulation Training Center

Other restriction (state/program)

Endowment

The A John Rose Endowment Fund

The Barry S. Hale Endowment Fund

The Bonnie Brackett Endowment Fund

The Brad Smith Endowment Fund

The Carol Zwick Endowment Fund

The Chris Julian Fralish Endowment Fund

The Colleen Thayer Endowment Fund

The Dana Oman Endowment Fund

The David J. Emmert Endowment Fund

The David Melby, PhD, Endowment Fund

The Deborah Taylor Tate Endowment Fund

The Dede Wallace Fund (supports services in TN - Davidson and contiguous counties) - *R

The Doug Leonard Endowment Fund

The Dr. Raghu Upender Endowment Fund

The Dr. Stephen J. Pritchard Endowment Fund

The Duke Legacy Endowment Fund (Florida Services)

The Ella P. Hayes Fund (supports services in TN) - *R

The Geoff McKim Endowment Fund

The George Bullard Stadler Endowment Fund

The George Spain Research Fund (supports behavioral health research) - *R

The Jack Wallace Endowment Fund

The James E. Sweeten Endowment Fund

The Janet Ayers Endowment Fund

The Jennifer Embree Endowment Fund

The Jennifer L. Bencie, MD Endowment Fund

The Joan C. Sivley Endowment Fund

The Jonathan Morphett Endowment Fund

The Joseph E. Roche Endowment Fund

The Josie Seybold Endowment Fund

The Kelly Crockett Endowment Fund

The Lee Ann Summers Ingram Endowment Fund

The Lee Brackett Endowment Fund

The Lieutenant General (Retired) Hubert G. Smith Endowment Fund

The Linda Trader Endowment Fund

The Lisa Hooker Campbell Endowment Fund

The Mark Faulkner Endowment Fund

The Michael J. McCalip Endowment Fund

The Mike Enos Endowment Fund

The Philip D. Krebs Endowment Fund

The Philippa M. Guthrie Endowment Fund

The R. Parker Griffith Endowment Fund

The Reed Farley Endowment Fund

The Reverend Bob Phillips Endowment Fund

The Reverend James T. Golden Endowment Fund

The Richard D. Sivley Fund (A) (supports children and youth services in TN - Davidson and contiguous counties) - *R

The Richard D. Sivley Fund (B) (supports children and youth services in TN) - *R

The Richard H. Fitzgerald Endowment Fund

The Sally Sheahan Endowment Fund

The Steven C. Holman Endowment Fund

The Steven E. Bryant Endowment Fund

The Terrye Davidson Endowment Fund

The Thomas W. (Tom) Mahler, Jr. Endowment Fund

The Timothy A. Knowles Endowment Fund

The Tom Johnson Endowment Fund

Name

This field is for validation purposes and should be left unchanged.

Centerstone Employee Giving Campaign

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