2024 Knock Out Hunger Donation Form
Information
Name
Employee ID
Email Addess
Location
Please select...
Amber Manor Care Center
Arlington Place Health Campus
Ashford Place Health Campus
Aspen Place Health Campus
Autumn Woods Health Campus
Avalon Springs Health Campus
Bethany Pointe Health Campus
Blair Ridge Health Campus
Boonesboro Trail Senior Living
Briar Hill Health Campus
BridgePointe Health Campus
Cedar Creek Health Campus
Cedar Ridge Health Campus
Clearvista Lake Health Campus
Cobblestone Crossing Health Campus
Cooper Trail Senior Living
Covered Bridge Health Campus
Creasy Springs Health Campus
Cumberland Pointe Health Campus
Cypress Pointe Health Campus
Forest Glen Health Campus
Forest Park Health Campus
Forest Springs Health Campus
Franciscan Health Care Center
Gateway Springs Health Campus
Genoa Retirement Village
Glen Oaks Health Campus
Glen Ridge Health Campus
Greenleaf Health Campus
Hampton Oaks Health Campus
Harrison Springs Health Campus
Harrison Trail Health Campus
Harrison's Crossing Health Campus
Hearthstone Health Campus
Homewood Health Campus
Liberty Station Health Campus
Mill Pond Health Campus
Morrison Woods Health Campus
North River Health Campus
Norwich Springs Health Campus
Novi Lakes Health Campus
Oakwood Health Campus
Orchard Grove Health Campus
Orchard Pointe Health Campus
Paddock Springs
Park Terrace Health Campus
Prairie Lakes Health Campus
RidgeWood Health Campus
River Pointe Health Campus
River Terrace Health Campus
Rivercrest Senior Living
RiverOaks Health Campus
Sanders Ridge Health Campus
Scenic Hills at the Monastery
Senior Living at Forest Ridge
Shelby Crossing Health Campus
Shelby Farms Senior Living
Silver Oaks Health Campus
Smith's Mill Health Campus
Springhurst Health Campus
Springview Manor
St. Andrews Health Campus
St. Charles Health Campus
St. Elizabeth Healthcare Center
St. Mary Healthcare Center
Stonebridge Health Campus
Stonecroft Health Campus
Stonegate Health Campus
Sun Prairie Senior Living
Taylor Springs Health Campus
The Glen
The Heritage
The Lakes of Monclova Health Campus
The Lakes of Sylvania
The Legacy at English Station - AL
The Maples at Waterford Crossing
The Meadows of Delphos
The Meadows of Kalida
The Meadows of Leipsic
The Meadows of Ottawa
The Oaks at Battle Creek
The Oaks at Belmont
The Oaks at Bethesda
The Oaks at Byron Center
The Oaks at Northpointe
The Oaks at Woodfield
The Residence at Waterford Crossing
The Springs at Lafayette
The Springs at Oldham Reserve
The Springs at Stony Brook
The Springs of Lima
The Springs Of Mooresville
The Springs Of Richmond
The Village at Orchard Grove
The Villages at Historic Silvercrest
The Villages at Oak Ridge
The Willows at Bellevue
The Willows at Bowling Green
The Willows at Citation
The Willows at East Lansing
The Willows at Fritz Farm
The Willows at Hamburg
The Willows at Harrodsburg
The Willows at Howell
The Willows at Okemos
The Willows at Springhurst
The Willows at Tiffin
The Willows at Willard
Thornton Terrace Health Campus
Triple Creek Retirement Community
Valley View Health Campus
Vienna Springs Health Campus
Village Green Health Campus
Violet Springs Health Campus
Walker's Trail Senior Living
Waterford Place Health Campus
Waunakee Valley Senior Living
Wellbrooke of Avon
Wellbrooke of Carmel
Wellbrooke of Crawfordsville
Wellbrooke of Kokomo
Wellbrooke of South Bend
Wellbrooke of Wabash
Wellbrooke of Westfield
West River Health Campus
Westlake Health Campus
Westport Place Health Campus
White Oak Health Campus
WoodBridge Health Campus
Wooded Glen
Woodmont Health Campus
Trilogy Home Office
Synchrony Home Office
Synchrony Columbus Pharmacy
Synchrony Charlotte Pharmacy
Synchrony Des Moines Pharmacy
Synchrony Grand Rapids Pharmacy
Synchrony Indianapolis Pharmacy
Synchrony Nashville Pharmacy
Syncrony Louisville Pharmacy
Synchrony Tampa Pharmacy
Synchrony Lab Services
Synchrony at Home Pharmacy
One-Time Payroll Deduction Donation Options
I wish to donate $____ to the Knock Out Hunger Drive.
$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