Workplace Campaign Pledge Form (2024) Fill out the form below to pledge for a payroll deduction through United Way of Acadiana. If your company is not listed in the dropdown below, please contact your HR representative. About YouName(Required) First Last Phone(Required)Birthdate(Required) Month Day Year Email(Required) Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country About Your CompanyCompany(Required)Select OneKeystone EngineeringLafayette Parish School SystemSCP HealthCommunity First BankPlease select your company from the dropdown menu. If from a school district, select your district. This field is hidden when viewing the formCommunity First Bank Branches(Required)Main OfficeNorthside BranchSpanish Trail BranchLoreauville BranchBroussard BranchYoungsville BranchBreaux Bridge BranchSt. Martinville BranchPinhook Tower BranchThis field is hidden when viewing the formAcadia Parish SchoolsSelect OneDistrict OfficeAPSB Head StartAcadia Parish Alternative SchoolArmstrong Middle SchoolBranch Elementary SchoolCentral Rayne KindergartenChurch Point Elementary SchoolChurch Point Middle SchoolChurch Point High SchoolCrowley KingdergartenCrowley Middle SchoolCrowley High SchoolEgan Elementary SchoolEstherwood Elementary SchoolEvangeline Elementary SchoolIota Elementary SchoolIota Middle SchoolIota High SchoolMartin Petitjean Elementary SchoolMermentau Elementary SchoolMidland High SchoolMire Elementary SchoolMorse Elementary SchoolNorth Crowley Elementary SchoolRayne High SchoolRichard Elementary SchoolRoss Elementary SchoolSouth Crowley Elementary SchoolSouth Rayne Elementary SchoolPlease select your school or location. Lafayette Parish SchoolsSelect OneLPSS Central OfficeAcadian Middle SchoolAcadiana High SchoolAlice Boucher Elementary SchoolBroadmoor Elementary SchoolBroussard Middle SchoolCarencro Bob Lilly Elementary SchoolCarencro Middle SchoolCarencro High SchoolCharles M. Burke Elementary SchoolCorporal Michael Middlebrook Elementary SchoolDr. Raphael A. Baranco Elementary SchoolDavid Thibodeaux STEM Magnet AcademyDuson Elementary SchoolEarly College AcademyEdgar Martin Middle SchoolEdward J. Sam Accelerated School of LafayetteErnest Gallet Elementary SchoolEvangeline Elementary SchoolGreen T. Lindon Elementary SchoolJ.W. Faulk Elementary SchoolJudice Middle SchoolKatharine Drexel Elementary SchoolL. Leo Judice Elementary SchoolL.J. Alleman Middle SchoolLafayette Middle SchoolLafayette High SchoolLerosen PreparatoryLive Oak Elementary SchoolMartial F. Billeaud Elementary SchoolMilton Elementary/Middle SchoolMyrtle Place Elementary SchoolNorthside High SchoolOssun Elementary SchoolOvey Comeaux High SchoolPaul Breaux Middle SchoolPrairie Elementary SchoolRidge Elementary SchoolS.J. Montgomery Elementary SchoolScott Middle SchoolSouthside High SchoolTruman Early Childhood Education CenterW.D. & Mary Baker Smith Career CenterWestside Elementary SchoolWoodvale Elementary SchoolYoungsville Middle SchoolPlease select your school or location. (Listed in alphabetical order.)LPSS Staff Employee ID#Payroll Deduction InformationI get paid....(Required) Weekly Bi-weekly Twice a Month Monthly Other If other, please fill out here.I want to donate....(Required)Select One$20 per check$15 per check$10 per check$____ other amount per checkYour general donation will go toward impacting health, education and financial stability in the Acadiana Community. I want to donate....(Required)Select One$20 per check$15 per check$10 per check$____ other amount per checkI want to donate my fair share.Your general donation will go toward impacting health, education and financial stability in the Acadiana Community. If other, ($___ amount per check) please fill out amount here.(Required)I am donating my Fair Share Yes (Fair Share = One hour's pay per month)Fair Share OptionsSelect OneI want to donate one hour of pay per month.I want to donate two hours or more of pay per month.If you would like to specifically designate your donation to a 501(c)(3) nonprofit organization in your local community, please input name here.Information must be included to process designation. You may select one organization per $100 donation. Incorrect entries benefit Untied Way of Acadiana. Administration fees apply. Please provide full address of your designation.ConsentConsent(Required) I agree to pledgeType Name Here(Required)
