Neighbor to Neighbor Support

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Neighbor to Neighbor

Programs & Services
We Support

How You Can Help

Enrollment Form

Enrollment Form PDF

I want to participate in helping my community, and here’s my pledge!
(Please complete this form as much as possible. We will contact you to finalize the details of your pledge.)

Yes, I authorize a regular automatic deduction per paycheck from
January 1, , through December 31,
that will automatically renew annually until I cancel by notifying my payroll administrator. (AVMF staff will contact you to finalize payroll deduction program.)

Yes, I authorize a regular automatic deduction per paycheck from
January 1, , through December 31, , ONLY. (AVMF staff will contact you to finalize payroll deduction program.)

Yes, I authorize a one-time direct contribution of
$ amount. (AVMF staff will contact you for payment.)

Please direct my gift to:

Neighbor to Neighbor $ per paycheck = $ per year
supporting community health and human services agencies

Aspen Valley Hospital $ per paycheck = $ per year
supporting patient services and medical equipment

Total Contribution

$

X

= $

or One-Time Contribution

$

Your Name (Employee)

Your Employer / Company Name

Company Human Resources Representative

Your Work Mailing Address

City

State

Zip

Best Phone Number to Reach You

Comments / Questions