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Employee Giving - Payroll Deduction Form

Indicates required field

First name

Last name

Former Last Name (if applicable)

Email (Please use your BJC email address)

We will mail all shirts and sweatshirts to your home. Items will be mailed out by January 26.

Home address

Home address 2

City/Town

State/Province

ZIP/Postal Code

Phone number

Employee ID# (10 digit # located on the back of your badge):

Facility where you work:

Position title:

Department

Unit/office/suite number

What shift do you regularly work?

Day shift

Night shift

Weekends only

Other

How I want to give (Note: You can contact the Foundation at any time to stop the deduction):

Per pay period deduction

One time deduction

Your per pay period deductions will last for one calendar year beginning with the January 2, 2026, payroll distribution. You may also opt in to apply no end date to your enrollment. You may contact the Foundation at any time to stop your enrollment in the program.

One year (26 pay periods) deduction

No end date

Per Pay Period Deduction

$1 / Pay Period: T-shirt

$3 / Pay Period: Sweatshirt

$5 / Pay Period: T-shirt & Sweatshirt

$10 / Pay Period: T-shirt, Sweatshirt, and Super Swag

$25 / Pay Period: T-shirt, Sweatshirt, Super Swag, and 1 Ticket to the Annual Health, Healing, & Hope Gala

One Time Deduction on January 2, 2026

$26: T-shirt

$78: Sweatshirt

$130: Sweatshirt and T-shirt

$260: Sweatshirt, T-shirt and Super Swag

$650: Sweatshirt, T-shirt, Super Swag, and 1 Ticket to the Annual Health, Healing, & Hope Gala

T-shirt Size (Unisex sizing):

XXL

XXXL

XXXXL

No T-shirt, Thank You

Sweatshirt Size (Unisex sizing)

XXL

XXXL

XXXXL

No Sweatshirt, Thank You

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How can we help?

BJC Health is committed to improving your health care experience and welcomes questions and feedback. We will respond during business hours, Monday-Friday, 8 a.m. to 5 p.m. If you have an urgent medical issue, please call 911.