Pledge Form Delta Dental

Invalid Submission Values

Step 1: Donor Information

First Name (required)

Last Name (required)

Mailing Address (required)

City, State, Zip (required)

Phone Number (required)

Email (required)

Example: janedoe@fakeemail.com

Step 2: How Would You Like To Give? (Please complete one of the options below.)

Option A: Payroll Deduction - starting January 1

Check this box if you want to be a CHAMP donor by donating an hour of your pay per month. (2021 salary) If you select this box you can skip down to Step 3.

Keep it simple...make me a CHAMP donor!

I want to select a specific annual donation amount. This is the total amount I would like for my 2021 pledge. It will be divided by 24 pay periods.

Example: 1,000.50

Option B: Credit Card

Credit Card Charge Frequency - begins January 1, 2021 unless another date is selected from the calendar below

My pledge amount

Example: 1,000.50

Please start my credit card contribution - begins January 1, 2021 unless another date is selected from the calendar below

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

Credit Card Number

Expiration Date (MM/YY)

CVV (code on back of card)

Step 3: Pledge Acknowledgment & Confirmation

Are you a CHAMP giver? (You are pledging to donate at least an hour of your pay, each month, to CAUW.) (required)

Yes

Are you a LEADERSHIP Giver? (May be combined with your spouse) (required)

$500+

$1000+

No (less than $500 pledge)

For LEADERSHIP Giving, please combine my gift with my spouse. (List spouse and their employer.)

I would like my thank you to be sent via(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)

Yes

Signature (required)