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Pledge Form Delta Dental

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    This form is for Delta Dental employee payroll deductions.

    If you prefer to donate via credit card, after completing the form below, please come back and click here.
    Step 1: Donor Information


    Step 2: How Would You Like To Give? (Please complete one of the options below.)
    Option A: Payroll Deduction - CHAMP donor - starting January 2023
    Check this box if you want to be a CHAMP donor by donating an hour of your pay per month. (2023 salary) If you select this box you can skip down to Step 3.
    Option B: Payroll Deduction - Specific Amount - starting January 2023

    Example: 1,000.50

    Option C: Bill Me - begins January 1, 2023
    Billling Frequency

    Example: 1,000.50

    Example: ##/##/####

    Step 3: Pledge Acknowledgment & Confirmation
    Are you an Evergreen giver? By checking the box below, I acknowledge that I want my gift to renew automatically each year. (required)
    Are you a CHAMP giver? (You are pledging to donate at least an hour of your pay, each month, to CAUW.) (required)
    Are you a LEADERSHIP Giver? (May be combined with your spouse) (required)
    I wish my gift to remain anonymous. (Please note: If you choose this option, you will not show up on any listings, even if you are a CHAMP or LEADERSHIP Giver.) (required)