WC Pledge Form – United Way of Acadiana

Workplace Campaign Pledge Form (2025-2026)

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 You

Name(Required)

First Last

Phone(Required)

Birthdate(Required)

Email(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

About Your Company

Company(Required)

Please select your company from the dropdown menu. If from a school district, select your district.

This field is hidden when viewing the form

Community First Bank Branches(Required)

This field is hidden when viewing the form

Acadia Parish Schools

Please select your school or location.

Lafayette Parish Schools

Please select your school or location. (Listed in alphabetical order.)

LPSS Staff Employee ID#

Payroll Deduction Information

I get paid....(Required)

Weekly

Bi-weekly

Twice a Month

Monthly

Other

If other, please fill out here.

I want to donate....(Required)

Your general donation will go toward impacting health, education and financial stability in the Acadiana Community.

I want to donate....(Required)

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 Options

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.

Consent

Type Name Here(Required)