Healthcare Heroes Form | San Mateo County Health Foundation

You can apply on this page to support the employee driven Healthcare Heroes program. To find out more about the program, visit this link. Thank you for your support!

HEALTHCARE HEROES DONATION FORM

ACKNOWLEDGEMENT (optional)

Send Acknowledgement of Donation to (optional):

PAYROLL DEDUCTION

I would like to donate every pay period (minimum $1.00 per pay period - enter $ in whole numbers)

AUTHORIZATION

I hereby authorize the Controller of San Mateo County to deduct my donation from my earnings each bi-weekly pay period. This authorization shall remain in effect until change is given by written notice from the employee to the Controller’s office.

DONOR RECOGNITION (optional):

I would like to be listed in the contribution list.

Please do not publish my name on the contribution list.

For further information contact John Jurow at (650) 573-2655 work / (650) 333-5634 cell — or email at jjurow@smcgov.org

San Mateo County Health Foundation

222 West 39th Avenue, San Mateo, CA 94403, Fax: (650) 573-3447

PONY # HOS316 Foundation • San Mateo County Health Foundation is a 501(c)(3) Tax ID #94-3116070

Thank you for your support!