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<h2><strong>Contact Information</strong></h2><div class=\'form-group\'><label for=\'FormField1_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Employee Name:<span class=\'fb-required\'>*</span></label><div class=\'col-sm-6\'>\
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</div></div><div class=\'form-group\'><label for=\'FormField3_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Title:<span class=\'fb-required\'>*</span></label><div class=\'col-sm-6\'>\
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</div></div><div class=\'form-group\'><label for=\'FormField6_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>I work at:</label><div class=\'col-sm-8\'><select  name=\'FormField6_2e48155b-083e-4426-843f-f4dbd6caf34f\' id=\'FormField6_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'form-control \' style=\'width: auto\'  data-export-label=\'I_work_at\' ><option value=\'\' selected>( Please Select )</option><option value=\'CCHC Lab Services\'>CCHC Lab Services</option><option value=\'Cape Cod Hospital\'>Cape Cod Hospital</option><option value=\'Cape Cod Human Services\'>Cape Cod Human Services</option><option value=\'Falmouth Hospital\'>Falmouth Hospital</option><option value=\'Heritage\'>Heritage</option><option value=\'JML Care Center\'>JML Care Center</option><option value=\'MACC\'>MACC</option><option value=\'VNA of Cape Cod\'>VNA of Cape Cod</option><option value=\'Other\'>Other</option></select></div></div><div class=\'form-group\'><label for=\'FormField7_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 hidden-label\'>Other Entity:</label><div class=\'col-sm-6\'>\
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</div></div><h2>Gift Options</h2><p>Please complete the fields associated with one of the following three gift options:</p><h4>1) Payroll Deduction</h4><p>Enter the amount you would like taken out of your paycheck each pay period. You may also enter a stop date if you would like to give a fixed amount.</p><div class=\'form-group\'><label for=\'FormField16_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Amount Per Pay Period:</label><div class=\'col-sm-4\'>\
<input type=\'text\' name=\'FormField16_2e48155b-083e-4426-843f-f4dbd6caf34f\' id=\'FormField16_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'form-control input-small \' value=\'\'   data-export-label=\'Per_Pay_Period\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label for=\'FormField36_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Optional Stop Date:</label><div class=\'col-sm-6\'><div class=\'clearfix\'><input type=\'text\' name=\'FormField36_2e48155b-083e-4426-843f-f4dbd6caf34f\' id=\'FormField36_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'form-control input-medium isDatePicker\'  data-format=\'mm/dd/yy\' data-export-label=\'Gift_Stop_Date\'  data-rule-dateFormat=\'MM/DD/YYYY\' style=\'float: left;\' /></div></div></div><h4>2) Outright Gift</h4><p>To Make a one-time gift, please mail your check, made payable to the Cape Cod Healthcare Foundation, to P.O. Box 370, Hyannis, MA 02601.<br>To make a gift by credit card, please provide:</p><div class=\'form-group\'><label for=\'FormField21_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Total Gift Amount:</label><div class=\'col-sm-4\'>\
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</div></div><div class=\'form-group\'><label  class=\'control-label col-sm-4 hidden-label\'>Card Type:</label><div class=\'col-sm-6 Chkbx\'><div><fieldset class=\'RadioGroup\'><div class=\'flow\'><input type=\'radio\' value=\'American Express\'  name=\'checkbox37\' id=\'FormField37_2e48155b-083e-4426-843f-f4dbd6caf34f_1\' class=\'right\' data-export-label=\'Card_Type\' ><label for=\'FormField37_2e48155b-083e-4426-843f-f4dbd6caf34f_1\'>American Express</label></div><div class=\'flow\'><input type=\'radio\' value=\'MasterCard\'  name=\'checkbox37\' id=\'FormField37_2e48155b-083e-4426-843f-f4dbd6caf34f_2\' class=\'right\' data-export-label=\'Card_Type\' ><label for=\'FormField37_2e48155b-083e-4426-843f-f4dbd6caf34f_2\'>MasterCard</label></div><div class=\'flow\'><input type=\'radio\' value=\'Visa\'  name=\'checkbox37\' id=\'FormField37_2e48155b-083e-4426-843f-f4dbd6caf34f_3\' class=\'right\' data-export-label=\'Card_Type\' ><label for=\'FormField37_2e48155b-083e-4426-843f-f4dbd6caf34f_3\'>Visa</label></div></fieldset></div></div></div><div class=\'form-group\'><label for=\'FormField38_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Card Number:</label><div class=\'col-sm-6\'>\
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</div></div><div class=\'form-group\'><label for=\'FormField39_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Exp. Date:</label><div class=\'col-sm-4\'>\
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</div></div><div class=\'form-group\'><label for=\'FormField41_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>CVV Code:</label><div class=\'col-sm-4\'>\
<input type=\'text\' name=\'FormField41_2e48155b-083e-4426-843f-f4dbd6caf34f\' id=\'FormField41_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'form-control input-small \' value=\'\' data-rule-maxlength=\'4\' data-msg-maxlength=\'You have exceeded the max length of 4 characters.\'  data-export-label=\'CVV_Code\'  placeholder=\'\'  />\
</div></div><h4>3) Vacation Hours</h4><p>You may choose to give in the form of vacation hours. Please enter the number of vacation hours you would like to give.</p><div class=\'form-group\'><label for=\'FormField23_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Total Hours to Give:</label><div class=\'col-sm-4\'>\
<input type=\'text\' name=\'FormField23_2e48155b-083e-4426-843f-f4dbd6caf34f\' id=\'FormField23_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'form-control input-small \' value=\'\'   data-export-label=\'hours_donated\'  placeholder=\'\'  />\
</div></div><h2>Support Options</h2><p>Which CCHC entity would you like your gift to support?</p><div class=\'form-group\'><label for=\'FormField26_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Support Choice<span class=\'fb-required\'>*</span></label><div class=\'col-sm-8\'><select  name=\'FormField26_2e48155b-083e-4426-843f-f4dbd6caf34f\' id=\'FormField26_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'form-control \' style=\'width: auto\' required data-msg-required=\'This field is required.\' data-export-label=\'Support_Choice\' ><option value=\'\' selected>( Please Select )</option><option value=\'Where Needed Most\'>Where Needed Most</option><option value=\'Cape Cod Hospital\'>Cape Cod Hospital</option><option value=\'Falmouth Hospital\'>Falmouth Hospital</option><option value=\'Heritage\'>Heritage</option><option value=\'JML Care Center\'>JML Care Center</option><option value=\'VNA\'>VNA</option><option value=\'Employee Hardship Assistance Fund\'>Employee Hardship Assistance Fund</option></select></div></div><h2>Your Recognition</h2><p>For recognition purposes, please enter exactly how you would like your name to appear in publications, or you may choose to remain anonymous.</p><div class=\'form-group\'><label for=\'FormField33_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'control-label col-sm-4 \'>Recognition Text</label><div class=\'col-sm-8\'>\
<input type=\'text\' name=\'FormField33_2e48155b-083e-4426-843f-f4dbd6caf34f\' id=\'FormField33_2e48155b-083e-4426-843f-f4dbd6caf34f\' class=\'form-control input-large \' value=\'\'   data-export-label=\'Recognition_Text\'  placeholder=\'\'  />\
</div></div><div class=\'form-group\'><label  class=\'control-label col-sm-4 hidden-label\'>Anoymous Recognition</label><div class=\'col-sm-6\'><div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'I would like to remain anonymous\'  name=\'827d1e92-77c3-4fae-9a19-3317350baaa0_FormField29_2e48155b-083e-4426-843f-f4dbd6caf34f_checkbox_29\' id=\'FormField29_2e48155b-083e-4426-843f-f4dbd6caf34f_1\' class=\'fo-right-margin-5\' data-export-label=\'Anoymous_Recognition\' ><label for=\'FormField29_2e48155b-083e-4426-843f-f4dbd6caf34f_1\'>I would like to remain anonymous</label></div></div></div></div><div class=\'form-group\'><label  class=\'control-label col-sm-4 hidden-label\'>Untitled35</label><div class=\'col-sm-6\'><div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Planned gifts can provide lifetime income. Check here if you&#39;d like more information.\'  name=\'827d1e92-77c3-4fae-9a19-3317350baaa0_FormField35_2e48155b-083e-4426-843f-f4dbd6caf34f_checkbox_35\' id=\'FormField35_2e48155b-083e-4426-843f-f4dbd6caf34f_1\' class=\'fo-right-margin-5\' data-export-label=\'planned_gift_info\' ><label for=\'FormField35_2e48155b-083e-4426-843f-f4dbd6caf34f_1\'>Planned gifts can provide lifetime income. Check here if you&#39;d like more information.</label></div></div></div></div><h2>Digital Signature</h2><p>I acknowledge through this digital signature this gift agreement will be made part of Cape Cod Healthcare Foundation&apos;s permanent records and is intended to serve as a guide to those who will administer these funds in the future.</p><div class=\'form-group\'><label  class=\'control-label col-sm-4 hidden-label\'>Digital Signature</label><div class=\'col-sm-6\'><div><div class=\'flow Chkbx\'><input type=\'checkbox\' value=\'Digital Signature\'  name=\'827d1e92-77c3-4fae-9a19-3317350baaa0_FormField30_2e48155b-083e-4426-843f-f4dbd6caf34f_checkbox_30\' id=\'FormField30_2e48155b-083e-4426-843f-f4dbd6caf34f_1\' class=\'fo-right-margin-5\' data-export-label=\'Digital_Signature\' ><label for=\'FormField30_2e48155b-083e-4426-843f-f4dbd6caf34f_1\'>Digital Signature</label></div></div></div></div>\
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