2023 Knock Out Hunger Donation Form
Information
Name
Employee ID
Email Addess
Location
Please select...
Anderson-Bethany Pointe Health Campus-112
Avon-Wellbrooke of Avon-166
Bardstown-Cooper Trail Senior Living-233
Batesville-St. Andrews Health Campus-120
Battle Creek-The Oaks at NorthPointe Woods-501
Bedford-StoneBridge Health Campus-115
Bellevue-The Willows at Bellevue-414
Bloomington-Hearthstone Health Campus-149
Bloomington-Stonecroft Health Campus-164
Boonville-Woodmont Health Campus-110
Carmel-Wellbrooke of Carmel-165
Cincinnati-The Glen-434
Colerain-Triple Creek Retirement Community-412
Columbus-Silver Oaks Health Campus-107
Commerce-Westlake Health Campus-503
Corydon-Harrison Springs Health Campus-180
Crawfordsville-Wellbrooke of Crawfordsville-167
Cynthiana-Cedar Ridge Health Campus-114
Danville-Walker's Trail Senior Living-231
Delphi-St. Elizabeth Healthcare Center-134
Delphos-The Meadows of Delphos-407
East Lansing-The Willows at East Lansing-507
Elkhart-Greenleaf Health Campus-132
Englewood-Cypress Pointe Health Campus-416
Evansville-North River Health Campus-186
Evansville-River Pointe Health Campus-111
Evansville-West River Health Campus-142
Ferdinand-Scenic Hills Care Center-303
Findlay-The Heritage-408
Fremont-Valley View Health Campus-403
Gahanna-Taylor Springs Health Campus-436
Genoa-Genoa Retirement Village-411
Goshen-The Maples at Waterford Crossing-124
Goshen-The Residence at Waterford Crossing-184
Grand Blanc-The Oaks at Woodfield-505
Grand Rapids-The Oaks at Byron Center-518
Greencastle-Mill Pond Health Campus-119
Greenfield-Springhurst Health Campus-125
Greensburg-Aspen Place Health Campus-150
Greenville-Village Green Health Campus-423
Hamilton-Gateway Springs Health Campus-439
Hanover-Thornton Terrace Health Campus-116
Harrison,-Harrison Trail Health Campus-442
Harrodsburg-The Willows at Harrodsburg-187
Hilliard-Norwich Springs Health Campus-437
Howell-The Willows at Howell-509
Indianapolis-Arlington Place Health Campus-160
Indianapolis-Clearvista Lake Health Campus-161
Jackson-RidgeCrest Health Campus-502
Jasper-St. Charles Health Campus-108
Kalida-The Meadows of Kalida-406
Kendallville-Orchard Pointe Health Campus-185
Kokomo-Waterford Place Health Campus-106
Kokomo-Wellbrooke of Kokomo-168
Lafayette-Creasy Springs Health Campus-133
Lafayette-St. Mary Healthcare Center-136
Lafayette-The Springs at Lafayette-162
Lapeer-Stonegate Health Campus-506
Lawrenceburg-Ridgewood Health Campus-143
Lebanon-Homewood Health Campus-104
Leipsic-The Meadows of Leipsic-409
Lexington-The Willows at Citation-148
Lexington-The Willows at Fritz Farm-147
Lexington-The Willows at Hamburg-146
Lima-Springview Manor-410
Lima-The Springs of Lima-433
Logansport-WoodBridge Health Campus-130
Louisville-Forest Springs Health Campus-154
Louisville-Franciscan Healthcare Center-137
Louisville-Glen Ridge Health Campus-126
Louisville-Park Terrace Health Campus-127
Louisville-The Legacy at English Station-210
Louisville-The Springs at Stony Brook-175
Louisville-The Willows at Springhurst-222
Louisville-Trilogy Home Office-900
Louisville-Westport Place Health Campus-145
Louisville-The Williow of Springhurst Pines-190
Louisville-Trilogy Flex Force-985
Louisville-Trilogy Real Estate Kentucky-910
Lowell-Cedar Creek Health Campus-156
Macomb-Shelby Crossing Health Campus-508
Madison-River Terrace Health Campus-157
McConnelsville-Highland Oaks Health Center-418
Miami Township-Vienna Springs Health Campus-440
Monclova-The Lakes of Monclova-422
Monticello-White Oak Health Campus-140
Mooresville-The Springs of Mooresville-174
Mount Washington-Sanders Ridge Health Campus-176
Muncie-Morrison Woods Health Campus-128
N. Baltimore-Briar Hill Health Campus-415
New Albany-Autumn Woods Health Campus-105
New Albany-Smith's Mill Health Campus-438
New Albany-The Villages at Historic Silvercrest-151
New Castle-Glen Oaks Health Campus-153
New Castle-Senior Living at Forest Ridge-152
Noblesville-Prairie Lakes Health Campus-141
Novi-Novi Lakes Health Campus-510
Okemos-The Willows at Okemos-504
Ottawa-The Meadows of Ottawa-430
Owensboro-Calumet Trace Senior Living-235
Peru-Blair Ridge Health Campus-144
Petersburg-Amber Manor Care Center-304
Pickerington-Violet Springs Health Campus-421
Plainfield charter Township-The Oaks at Belmont-519
Princeton-RiverOaks Health Campus-117
Richmond-Forest Park Health Campus-123
Richmond-The Springs of Richmond-173
Romeo-Orchard Grove Health Campus-512
Romeo-The Village at Orchard Grove-527
Scottsburg-Hampton Oaks Health Campus-121
Seymour-Covered Bridge Health Campus-109
Shelbyville-Ashford Place Health Campus-118
Shelbyville-Shelby Farms Senior Living-234
South Bend-Wellbrooke of South Bend-169
Spencer-Owen Valley Health Campus-101
Springfield-Forest Glen Health Campus-401
Springfield-Wooded Glen-429
Sylvania-The Lakes of Sylvania-427
Tell City-Oakwood Health Campus-103
Terre Haute-Cobblestone Crossings-129
Terre Haute-Harrison's Crossing Health Campus-163
Tiffin-The Willows at Tiffin-435
Valparaiso-Avalon Springs Health Campus-139
Vincennes-BridgePointe Health Campus-131
Wabash-Wellbrooke of Wabash-170
Warsaw-Paddock Springs-302
Washington-The Villages at Oak Ridge-305
West Chester-The Legacy at Liberty Ridge-211
West Lafayette-Cumberland Pointe Health Campus-135
Westfield-Wellbrooke of Westfield-171
Willard-The Willows at Willard-424
Winchester-Boonesboro Trail Senior Living-232
Zanesville-The Oaks at Bethesda-425
Zanesville-The Oaks at Northpointe-419
Synchrony Columbus Pharmacy -810
Synchrony Des Moines Pharmacy – 860
Synchrony Grand Rapids Pharmacy – 820
Synchrony Indianapolis Pharmacy – 801
Synchrony Jeffersonville Pharmacy – 805
Synchrony Louisville Pharmacy – 800
Synchrony Nashville Pharmacy – 850
Synchrony Tampa Pharmacy -870
Synchrony Lab Services – 890
Synchrony Home Office -3510
Synchrony Charlotte Pharmacy – 865
LaGrange-The Springs at Oldham Reserve-177
Sun Prairie -Sun Prairie Senior Living-572
One-Time Payroll Deduction Donation Options
I wish to donate $____ to the Knock Out Hunger Drive. (HUN)
$100
$50
$25
Other
Other
PTO Hour Donation Option
I wish to donate ____ PTO hours to the Knock Out Hunger Drive (HOURLY EMPLOYEES ONLY). (HUN)
40
16
8
1
Other
Other
Total Value of Food Donation:
Total Cash Value of Non-Cash Gifts/Cash Value of Pounds of Food
Includes value of Toys, Food, and other items. $1=4 pounds of food. The cash value of the donation is what must be reported here, rather than pounds. If you have canned food items take the weight and divide by 4.
Description of items donated:
Donation Agreement
Please read and check below: I authorize the Company to initiate my donation through payroll if applicable. If you are filling out an event entry payroll donations would not apply. Donations are tax deductible. I understand that required payroll taxes will be withheld on PTO donation amounts and only the net (after tax) proceeds will be transferred to the Trilogy Foundation. I understand that this donation is voluntary.
Do you accept the above agreement?
I Agree
Contact Information