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Genesys Friendship Fund - Donation Form

The Friendship Fund, co-sponsored by the Employee Participation Committee of the Genesys Health Foundation and the Medical Staff, is a program created by Genesys employees, volunteers and physicians to help each other in times of need. Eligibility for a Friendship Fund grant is based upon need due to a hardship or crisis situation such as utility shut-off notice, food for children, eviction notice, expenses related to sudden family illness or death, emergency car repair, imminent loss of medical benefits or other special circumstances.



Yes! I would like to make a donation to the Genesys Friendship Fund and become a member of the Elzeard's Club.

(Bolded fields are required.)

Employee Name:
Street Address:
City:
State:
Postal Code:

E-mail Address:
Telephone #:

Title
Department
Shift

Total Gift Amount
Credit Card Number:
Expiration Date:
Card Type
/
Security code: (on back of card)


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