| 2005
YES Campaign Form
1. Please fill in employee information section on
pledge form.
2. Select one of four ways to give. Check the box and
signyour name where it applies.
3. Designate your gift to support an area important to you.
4. Return pledge form and/or check to the 2005 YES
Campaign,
c/o Health Sciences Foundation, 18 Bee Street, P.O. Box 250450,
Charleston,
SC 29425. Or fax pledge form to 792-8934.
4. If you have any questions, contact Kristin Romness in
the YES
Campaign Office at 792-1973.
Please print
Dr./Mr./Mrs./Ms.___________________________________________________________________________________________/__________________
First
Middle
Last
Date
Home
address___________________________________________________________City/
State/Zip Code_________________________________________
Department PO Box #________________________ Department
#_____________________Department Phone
#___________________________________________
SSN____________________ E-mail
address______________________________________________________
Ways of Giving:
______Check. Your enclosed check should be made payable to the
Health Sciences Foundation.
____$1,000 (Society of 1824 Membership) _____$500 _____$250
_____$100 _____$50______ Other
______ MUSC payroll deduction
______MUHA payroll deduction
______UMA Payroll deduction
______CFC payroll deduction
______Please
deduct pledge from payroll for one year only. I will renew my pledge
during next year's campaign.
______Please automatically renew my payroll deduction pledge until
otherwise
notified by me.
Pay period: (Please circle one)
Monthly
or
Biweekly
$ _______ per paycheck through June 2006.
I
authorize the above payroll deduction amount beginning July 2005
to the Health Sciences Foundationof MUSC.
Employee Signature______________________________________________________________________
______ One time pledge to be paid by check or credit card by
June 30, 2006.
Gift amount $_______________
Please send me a reminder in
__________________ (specify month)
_____Credit card #________________________________________
Exp. date________ Gift amount $____________
Circle one: VISA
MasterCard American
Express
(Must include
security #)________________
Employee
Signature____________________________________________________________________
(required for credit card processing)
Gift Designations
_____YES Family Fund:
The YES Family Fund was established in 1999 as another way for
employees to benefit from their contributions to the YES Campaign. Now
in its sixth year of providing grants, the fund has aided areas from
education to patient care to research. Watch for 2005 grant recipients
to be announced during the campaign.
_____Other: A complete listing of active funds within the
Health Sciences Foundation
is found at the bottom of this page, or call Krisitn Romness at
792-1973.
Please indicate how you would like to designate your gift. Your gift
can
be dispersed to more than one fund.
1._____________________________________________
__________________________________________
Designated area of need
Amount per pay period
2._____________________________________________
______________________________________________
Designated area of need
Amount per pay period
Honor/Memorial Gifts
I would like to make a gift in honor
of:___________________________________
or in memory of:_________________________________________
Relationship to
deceased/honoree:________________________________________________________________________________________
Send notification of this gift to:
Name______________________________________________________________
Address__________________________________________________________
City/State/Zip
Code________________________________________________________________________________________________
Bequests and Life Income Gifts
For more information on planned gifts, contact Jane McCullough,
director
of planned giving, 792-4280, or mcculloj@musc.edu
Print and return the form to the Health Sciences Foundation. Gifts may
be made payable to the Health Sciences Foundation of the Medical
University
of South Carolina.
UMA Matching Gift Options:
All UMA employees who contribute their YES Campaign gift to the
Hospital
Authority Building Fund are eligible for a dollar for dollar match. UMA
will match the first $50,000 contribution to this fund. There is no
minimum
or maximum gift required to utilize the match. You can make a gift to
this
fund via payroll deduction or an outright gift.
I wish to utilize my UMA Matching Gift Option to the Hospital
Authority
Building Fund.
My personal gift is $____________. My matching gift is $_____________.
Active Funds
Centers
Autoimmune Diseases Center; Center for Drug and Alcohol; Center for
Health Care Research; Center on Aging; Children’s Hospital; Children’s
Research Institute; Digestive Disease Center; Gazes Cardiac Institute;
Harper Student Wellness Center; Heart and Vascular Center; Hollings
Cancer
Center; Institute of Psychiatry; Library Fund; National Crime Victims
Center;
Neuroscience Institute; Storm Eye Institute; Transplant Center;
Colleges
Dental Medicine – James B.
Edwards
College of Dental Medicine Building Fund; Annual Fund; Arthur L.
Haisten
Fund; Dental Program for Children with Special Needs; Dr. William O.
Engler
Quadrant; Dr. George C. McTeer Sr. Scholarship; John Buhler
Lectureship;
John Meador Sneed Scholarship; SCDA College of Dental Medicine
Endowment;
Stine Dental Lifelong Learning
Graduate Studies – Annual
Fund;
Graduate Studies Fund; Medical Scientist Training Program; Outstanding
Teacher of the Year Award
Health Professions –
Annual Fund
(please specify program); CHP Building Fund; CHP Scholarship; CHP
Support
Fund; Gouge PA Scholarship; Mary Anne Cone Scholarship; Valerie T. West
Educational Fund; Will Hagood Memorial Fund
Medicine – Warren Adkins,
M.D.,
Society Fund; Annual Loyalty Fund; BEE Fund; Class Scholarship; C. W.
Legerton
Jr. Lectureship; Dr. William H. Lee Memorial Fund; G. R. Hennigar
Professorship;
H. Oliver Williamson Lectureship; Hiram B. Curry Endowed Chair; Horace
Smithy Visiting Professorship; Institute of Human Values in Health
Care;
James B. Edwards Scholarship; Melvin H. Knisely Scholarship; Michael E.
Assey, M.D., Endowed Chair; Norman H. Bell, M.D., Endowed Chair; Perot
Chair in Neurosurgery; Pitts memorial Lectureship/Medical Ethics;
Pratt-Thomas
Lectureship; Residents/Fellows Fund; Richard H. Gadsden Lectureship;
Siegling
Chair for Orthopedics; Storm Eye Institute Endowed resident’s Fund;
Stephen
D. Canady Memorial
Nursing – Annual Fund; Ann
D. Edwards
Endowed Chair; Anthony Pirraglia Scholarship; Caring for the Community
(specify program; Doctors Honoring Nurses; Margaret Anne Kerr
Scholarship;
Nurse to Nurse Scholarship; Nursing Wound Management; Parish Nurse
Program;
Sarah Piechnik Scholarship
Pharmacy – Dr. John F.
Cormier Dean’s
Fund; Pat Sharpe Students’ Fund; Annual Fund; Building Fund; Support
Fund;
Faculty and Student Development Fund; Residents Fund; Department of
Pharmacy
and Clinical Sciences; Department of Pharmaceutical Sciences Fund;
Charles
and Carol Cooper Endowed Chair Fund; Michael Araneo Endowed
Scholarship;
T. Edward Childress III and John P. O’Brien Jr. Endowed Scholarship;
Charles
F. Cooper Sr. Endowed Scholarship; Dr. Alvin F. Dodds Endowed
Scholarship;
Dr. William H. Golod Endowed Scholarship Fund; F. Joseph Hodge Endowed
Scholarship Fund; Dr. and Mrs. Arnold W. Karig Endowed Scholarship
Fund;
Low Country Diagnostics Endowed Scholarship Fund in Memory of Margaret
Mizzell Inabinett; D. Julian E. McGill Endowed Scholarship Fund; Vivian
F. Platt Memorial Endowed Scholarship; Harry L. Rickenbacker, DDS,
Endowed
Scholarship; Dick and Emily Schwerin Endowed Scholarship
Departments
Anatomy; Anesthesia and Perioperative Medicine; Biometry Support; Burn
and Trauma Unit; Cardiology; Cell Biology and Anatomy; Child Life;
Child
Psychiatry; Clinical Psychiatry; Dermatology; Diagnostic Radiology;
Emergency
Medicine; Family Medicine; Gastroenterology; Gregory-Chandler
Expendable
Chair in Family Medicine; HPPA General Support; Internal Medicine
Support;
Microbiology and Immunology; Neonatal Intensive Care; Nephrology;
Neurology;
Neurosurgery; Orthopaedic Surgery; OB/GYN; OB/GYN Resident Fund; OB/GYN
Hester Chair; Otolaryngology; Pathology and Laboratory medicine;
Pediatric
intensive Care; Pharmacology; Pharmaceutical Sciences Support Fund;
Pharmacy
Services; Plastic Surgery; Psychiatry; Pulmonary/Critical Care;
Radiation
Oncology; Radiology; Surgery; Transplant Support; Trauma Center;
Urology
General University
ACBC Burned Children’s Fund; Annual Fund; Apple Tree Society; Camp
Bluebird Cancer Fund; Cecil and Jones Scholarship; Cultural Projects
Council;
Friends of Nursing; General Scholarship and Loan; Higgins Memorial
Scholarship;
HSF Developing Scholars; Lighten Up Program; Minority Student
Scholarships;
MUSC Dietetic Internship; MUSC International Committee; MUSC Student
Programs;
St. Luke’s Chapel Restoration; Pastoral Care/Hospital Chapel
Renovation;
Presidential Scholars Program; Teaching Excellence Awards Program;
Trident
Area SAFE KIDS; Waring Library Society
Hospital
Clinical Psychiatry; Hospital Authority Building; Medical Equipment;
Palmetto Pavilion; Staff Development and Training
Research and Education
Alzheimer’s Research and Clinical; Anesthesia Aplastic Anemia;
Arthritis;
Basic Science Auditorium/Children’s Theatre Chair Fund; Bone Marrow
Transplant;
Brain Tumor Research; Breast Cancer; Cancer Prevention and Control;
Cancer
Research Fund; Cardiology Fellowship Award; Cerebral Aneurysm Research;
Cystic Fibrosis; Deep Brain Stimulation; Diabetes Research and
Education;
Endocrine Training Fund; Gastrointestinal Oncology; Glaucoma; Grants
and
Contracts Accounting; Hanna Retinal Research Laboratory; Hannun
Research
Enhancement Fund; Head and Neck Cancer; Health Disparities; heart and
Lung
Transplant; Hollings Cancer Center/Dragon Boat; Hypertension
Initiative;
Infectious Disease and HIV, Research and Education; Liver; Magill
Research
Center; Melanoma Medicine Research and Education; Memory
Disorders/Alzheimer’s;
Mental Health; Metabolism; Molecular Oncology Support; Movement
Disorders
Support Fund; Multiple Sclerosis; Nephrology Support; Neurology
Support;
Neuroscience Educational Fund; Nuclear Cardiac Research Fund;
Osteoporosis
Fund; Parkinson’s Disease Research; Pediatric Cardiology; Pediatric
Endocrinology;
Pediatric Neurology; Pediatric Oncology; Pediatric Sickle Cell Anemia;
Sea Island Families Project Sugar; Student Research Day; Think First
Program;
Vascular Surgery; Vision Rehabilitation; MUSC Family
YES Campaign Contact Information
If you have any questions, contact Kristin Romness, employee
campaign
coordinator, at 792-1973.
Return pledge form and/or check in an envelope and mail to the
2005 YES Campaign, c/o Health Sciences Foundation, 18 Bee Street, P.O.
Box 250450, Charleston, SC 29425. If paying by credit card or payroll
deductions,
forms may also be faxed to 792-8934.
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