Survey - Grow Together Payroll Deduction Sign Up

Please provide your contact information below:


*	First Name: Required
*	Last Name: Required
*	Email: Required
	Phone Number:
	Please check this box to receive or continue receiving periodic email updates from Loma Linda University Health

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Question - Required - Employee ID# (Not EID)

*

Question - Required - Entity
Please make up to 1 selection from the choices below.

	Medical Center
	Children's Hospital
	University
	Murrieta
	Shared Services
	Health Care
	Behavioral Medicine Center
	LLUAHSC

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Question - Required - Mailing Address

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Question - Required - City

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Question - Required - Zip

Question - Not Required - Automatic Payroll Deduction
Please make up to 2 selections from the choices below.

	$25
	$15
	$10
	$5
	$2.50
	$1

Question - Not Required - Custom amount per pay period

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Question - Required - Starting Payperiod Date

Question - Not Required - Update Current Deduction
Please make at least 1 selection from the choices below.

	Please add this to my existing deduction
	Please replace my existing deduction

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Question - Required - Voluntary payroll deductions are offered to employees as a matter of convenience. The employer reserves the right to change the requirements for participation in this program at any time and without advance notice. By checking the box below, you hereby acknowledge the following:
Please make up to 1 selection from the choices below.

I specifically, freely, unequivocally, and voluntarily request that the above deduction be taken from my paycheck.

I Would Like to Give to An Area that I'm Passionate About

Question - Not Required - Areas
Please make between 1 and 3 selections from the choices below.

	Area of Greatest Need
	Employee Family Fund
	COVID-19 Clinical Care Fund
	COVID-19 Student Relief Fund
	Adult Hospital
	Children's Hospital
	Education
	Research
	Cancer

Question - Not Required - Other

Question - Not Required - Additional
Please make up to 4 selections from the choices below.

	I would like to receive communications, including receipts, via email.
	I am interested in becoming an Ambassador for the Grow Together Employee Giving Program.
	I am interested in learning how a planned gift (trust, annuity, etc.) can provide income to me and help people served by LLUH.
	LLUH is already in my estate plans.

NOTE: You will receive a year end receipt of your total annual deductions.