Cape Breton Regional Hospital Foundation Payroll Deduction Form
By supporting the Regional Hospital Foundation’s Payroll Deduction Program, you are helping purchase the equipment needed to provide the best care for the thousands of patients who rely on the Regional Hospital every year. Thank you for your continued support!
Please complete this form and return it by fax, mail or internal mail to:
Cape Breton Regional Hospital Foundation or
45 Weatherbee Road, Ste 209 Regional Hospital
Sydney, NS B1M 0A1 2nd Floor
Fax (902) 567-7916
Phone Number: (h) (w) ____________________
Hospital Site: ________________________________________________
I am pleased to commit to the Employee Payroll Deduction Program.
The deduction amount shall be: ____________ each pay period.
Date of first deduction: ______________ Area of care:___________________________
Employee Signature: __________________________ Date: ________________
If you choose the Cape Breton Regional Hospital Foundation, please mark which designated area you would like your donation to go to:
Area of Greatest Need
Cancer Patient Care Fund
Breton Cancer Centre
Coronary Care Unit
Heart Lung Wellness Centre
Intensive Care Unit
Mental Health Units
Medical Surgical Inpatient Units
Mom and Baby (Obstetrics, Mom/Baby Clinic, Breastfeeding Clinic)
Neonatal Intensive Care Unit
Palliative Care Unit
Rehabilitation Services (Physiotherapy, Occupational Therapy)
Renal Dialysis Unit
Respiratory Services (Respiratory Therapy Dept., Chest Clinic)
**Important, please read: This deduction will continue until changed or cancelled by the employee through written notification to the Foundation which is in receipt of your donations.