2024-2025 Pledge Card

Payroll Deduction

Payroll Deduction: Dollar amount per pay period

$5

$10

$20

$25

$50

Other

$ per pay period $

Number of Pay Periods

1 time

10 pay periods

12 pay periods

24 pay periods

26 pay periods

TOTAL

TOTAL ANNUAL PAYROLL DEDUCTION: $ 0

NOTE: Payroll deductions for this donation will begin January.

Cash or Check Donation

To donate by cash or check, please print this form and drop off to your supervisor or campaign ambassador or OMC human resources. You can also mail to United Way of Clallam County, PO Box 937, Port Angeles, WA 98362.

$5

$10

$20

$25

$50

Other…

Enter Amount $

If donating by credit card or ACH, please CLICK HERE to exit this form and complete your online transaction.

Your Name

Title

First

Middle

Last

Suffix

Your Contact Information

Company

Personal Email

Personal Phone #

Home Address

City

State

ZIP Code

The following check boxes apply to communications from United Way:

Don’t list my name.

Don’t release my name to agencies I designate.

PLEASE DISTRIBUTE MY GIFT AS FOLLOWS

By selecting the United Way Community Care Fund, I want my gift to be invested in the most critical needs in Clallam County and distributed in a way that will make the greatest impact in the community.

United Way Community Care Fund

Please ensure your distributions equal the total contribution you listed above. Distributions not designated below will be allocated to the United Way Community Care Fund.

Amount to United Way Community Fund $

Amount to American Red Cross Northwest Region - South Puget Sound and Olympics $

Amount to Boys & Girls Clubs of the Olympic Peninsula $

Amount to Camp Beausite Northwest $

Amount to Catholic Community Services of Western Washington (CCSWW) $

Amount to Clallam-Jefferson County Pro Bono Lawyers $

Amount to Clallam Mosaic $

Amount to Concerned Citizens $

Amount to Emergency Preparedness Fund $

Amount to First Step Family Support Center $

Amount to Forks Community Food Bank $

Amount to Get it Done Fund $

Amount to Habitat for Humanity of Clallam County (HFHCC) $

Amount to Healthy Families of Clallam County $

Amount to Lutheran Community Services Northwest $

Amount to Mariposa House $

Amount to Olympic Community Action Programs $

Amount to Olympic Peninsula YMCA $

Amount to Peninsula Behavioral Health $

Amount to Peninsula Dispute Resolution Center $

Amount to Sarge's Veteran Support $

Amount to Serenity House of Clallam County $

Amount to Society of St. Vincent de Paul - St. Joseph Conference $

Amount to St. Andrew's Place $

Amount to The Dungeness Valley Health & Wellness Clinic (Sequim Free Clinic) $

Amount to West End Youth & Community Club $

Other Non-Profit

Amount to Other $

Leadership Giving - $250 or More

United Way of Clallam County has a recognition program for individuals and couples who donate $250 or more to United Way and Partner Agencies.

My donation either individually or combined with a spouse totals $250 annually or more

How would you like your name(s) recognized:

Agreement

SIGNATURE AUTHORIZING CONTRIBUTION and acknowledging no goods or services were provided in exchange for this contribution.

Signature

Thank you for supporting your community!

WORKPLACE PLEDGE CARD