William Osler Health System Foundation

This Is MY Hospital

Please fill out the form below to complete your registration. All questions marked with * are required.

Title

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Street 2:

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Field Is Required At which site(s) do you work: (select all that apply) Please make at least 1 selection from the choices below.

What is your department?

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My Payroll Deduction Authorization

Field Is Required I want to join the Campaign and hereby authorize William Osler Health System to deduct the amount below through payroll deduction as a charitable donation to William Osler Health System Foundation. I understand that my annual T4 slip will include the official donation amount for income tax purposes.

My Gift Direction

Field Is Required I want to direct my donation to the approved capital project or equipment to the following hospital/department:

If you chose to direct your gift to a specific department please provide the department name. (Maximum response 255 chars, approx. 5 rows of text)

Please share why you support Osler Foundation? (Maximum response 255 chars, approx. 5 rows of text)

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Thank you for registering!

Field Is Required By selecting 'Yes', you are providing authorization to Osler Foundation to enroll you for the This Is MY Hospital Campaign.

Field Is Required Date: