Employee Name:
Employee SSN:
Date:
***-**-
Campus:
I would like to make a monthly contribution to the GISD Educational Foundation through payroll deduction.
Seashell ($5/ month)
Crab ($10/ month)
Lifesaver ($20/ month)
Lobster ($30/ month)
Octopus ($40/ month)
Dolphin ($50/ month)
______Other; I would like to make a monthly contribution of _____/ month.
If you selected the Lifesaver level or above ($20 or more per month), please circle your t-shirt size:
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Other__________
I would like to make a one-time contribution of $________ to the GISD Educational Foundation through payroll deduction.
I would like to make a one-time contribution of $________ to the GISD Educational Foundation by cash, check or credit card.
Circle Card Type: Visa
MasterCard
Discover
AMEX
Card #: _____________________________________________________________
Name on Card: ___________________________________________________
Zip Code: ______________ Exp. Date:_____________________________
I would like for half of my donation to be directed to the campus of my choice. (Only one selection may be made.)
Austin
Crenshaw
AIM
DAEP
Ball
Morgan
Burnet
Oppe
Central
Coastal Elem.
Parker
Scott
Coastal Middle
Weis
I would like for my entire donation or the balance to be restricted to the Grants to Teachers & Schools program.
I would like for my entire donation or the balance to be unrestricted.
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I understand that if I select to make a monthly contribution, my contribution will continue to be
deducted from my paycheck as long as I am employed by GISD until I ask for it to stop.
I understand that I can ask for my monthly contribution to stop at any time by contacting
[email protected] and [email protected].
I understand that I can increase or decrease the amount I contribute monthly by submitting a new
copy of this form to [email protected].
I understand that the first monthly deduction or my one-time deduction will begin during the October
2016 pay period.
I understand that contributing to the Employee Appeal does not give favor or preference to any
grant applications I may submit to the Galveston ISD Educational Foundation in the future.
I understand that I am not required to make a contribution to the Employee Appeal and doing so
does not give me favor or preference as an employee of GISD.
I understand that if I receive spring event tickets for my donation, only the portion of my donation that
exceeds the fair market value of the tickets is tax deductible as allowed by the IRS.
Signature:
Date:
Please return this form by September 30, 2016 to [email protected], or call (409) 766-5157 to schedule a form pickup at
your campus.