Team Member Giving Form

Please use the form below to initiate or change your donation through Novant Health Legacy or Novant Health New Hanover Regional Medical Center (NHNHRMC) payroll deduction.

If you currently have an ongoing payroll deduction and do not wish to make any changes, you do not need to complete the below form as your gift will continue each pay period – even when a new calendar year begins. If you would like to adjust your donation amount or make a change to your fund designation, please complete the form below.

Contact Information

Last Name:

First Name:

Employee Email Address:

Mobile Phone:

Employee ID Number:

Department:

Home Address

Street Address:

City:

State:

ZIP Code:

Donation Information

Do you have an active Foundation payroll deduction?

YesNo

What change are you looking to make?

I wish to update my current allocations.I would like to end my active payroll deduction.

Please complete the following steps to initiate your payroll deduction.

I wish to payroll deduct the following amount each pay period:

Other amount I wish to payroll deduct each pay period:

I wish to designate my deduction to the following Novant Health Foundation:

I wish to designate my deduction to the following area of support:

DeductionCode

Share why you are giving:

Please note the sum of all deductions provided above equals the total deducted per pay period and will be an ongoing donation each paycheck. Team members may select up to six (6) deductions.