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Change Starts Here

Be the Change with as

little as $2.00 a Pay!

2013 PLEDGE FORM A New Form Must be Completed Each Year

School / Site__________________________________________________ Employee Group ____________________________

Name________________________________________________________ Employee ID ________________________________

Legal name (please print)

Home Address_________________________________________________City _______________________________________

Required for tax receipt

Postal Code_______________ Telephone __________________________ E-Mail______________________________________

Option #1 - Payroll Deduction

Payroll deduction is available to permanent full and part
time salaried employees. Deductions begin in January and
continue to December. Please check applicable box:
I wish to donate:
q$2 q $5 q $10 q $_______ per pay.
q Teaching / PSSP / Principals / Vprincipals (26 pays)
q12 Month Support Staff (26 pays)
q10 Month Support Staff (22 pays)
qManagers / Superintendents (12 pays)
My Total Donation is $________________

Option #2 - Monthly Payment

I would like my donation to be directed to

the following United Way:
q Elgin-St. Thomas q London-Middlesex q Oxford

Donor Choice Program

(completion is optional) United

Way ensures accountability. Only through United Way can one gift
support hundreds of essential services. Each United Way is run by
a Board of locally trained volunteers who ensure that the funds are
allocated to agencies identified within its community. As an option,
the Donor Choice program provides donors the opportunity to
determine where you would like your donation directed.
If you would like to direct part of your donation specifically to a
United Way member agency or a registered Canadian charitable
organization please complete the following: (A small fee to recover costs

will be charged to charities not affiliated with United Way. Minimum $25 gift per
designation is required).

Monthly payment is available to all staff. I wish to donate

$__________ on the 15th of each month for ______
months. Please check applicable box:
q Chequing Account (please attach void cheque)

Name of Organization

q Post-dated cheques (please attach cheques)

q Credit Card (please provide details below ** )
q My Total Donation is $ _______________

Option #3 - One Time Gift

One time gift - Cheque / Cash (enclosed) or Credit
Card (please provide details *) Payable to United Way
My Total Donation is $ ______________
* Credit Card Details: q MC


q AMEX**

Card Number _____________________________

Expiry date__________________CVV___________
For security reasons we need your CVV or Credit Card verification number. Your CVV number is the last 3 digits on the back of your card, printed above the signature area. ** AMEX for Elgin & London/Middlesex only

Dollars or Percentage







q I wish my name and address to be forwarded with the donation

to the above organization.

q I do not wish to be publicly recognized for my gift. Please make

me anonymous in any print or digital media recognizing donors.

The United Way is committed to protecting your privacy. Your information will only be used to help us in
our campaign, properly administer, acknowledge and recognize gifts, process and receipt your donation
and fulfill your information requests. The United Way does not sell or lease donor information. If you
have any questions about our privacy policy, please contact your local United Way.

See Reverse for Tax Tips!

Submit Your Pledge Form in a Sealed Envelope

Employee Signature___________________________________________________ Date______________________

(required for payroll deduction, credit card and pre-authorized payments.)

2012 Key Contributors

The TVDSB and the United Way organizations of London-Middlesex, Elgin and Oxford are proud to recognize
some very dedicated individuals who were the driving forces in the 2012 United Way Campaign. It takes a
special individual who is highly motivated and dedicated to make a difference - to be the change.
Tanya Beattie (Lockes Public School)

Cynthia Flear (Jack Chambers Public School)

Don Whitehead & Ezra Nicholson (Central Elgin C.I.)

Don and Ezra led the Central Elgin campaign to new heights last
year. Don inspired the staff to increase their contributions by 31
per cent this year. Ezra organized an amazing StairClimb team
of 30 students from his leadership class who trekked around the
Timkin Centre and raised more than $660. What a testament to

Becky Mills (Medway High School)

Tanya encouraged her colleagues to give more in 2012 and her

efforts resulted in an increase of 25 per cent of staff donations.
Tanya also ensured students were able to participate in raising
money and awareness for United Way one step at a time. On
a sunny October day, Tanya, staff members and students raised
more than $250 by walking.

When Cynthia took on the role of United Way Site Representative

last year, she implemented changes to special events, arranged
a staff presentation and increased school-wide awareness of
the United Way and funded agencies. The school doubled their
campaign results in 2011. That growth was maintained in 2012
and employee giving increased once again.

Becky did an exceptional job leading the students and staff in

organizing the district-wide kickoff of the TVDSB United Way
campaign. In addition, Becky worked with students to plan and
run new and exciting special events including Medways first ever
StairClimb team. As a result of Beckys efforts, Medway doubled
employee giving and more than tripled the schools special event
contribution in 2012.

Michelle Dench (Glendale High School)

Motivating students to participate in the StairClimb, inviting
United Way to give a presentation and promoting special
events including hat day and a perogie bar were some of
the innovative ways that Michelle encouraged staff and student
participation in the 2012 United Way Campaign. Congratulations
to both Michelle and Glendale for a job well done!

Donna Robinson & Adam McNiff

(Oakridge Secondary School)

Donna and Adam worked closely with the students at Oakridge
to plan one of the best Oaktober fall campaigns yet. Under their
leadership, the students demonstrated creativity and passion
for helping the community while making it fun. Through events
like United Way Football, StairClimb and Homeroom Challenge,
Oakridge students raised more than $14,000 for United Way.

Cindy Walker (Innerkip Public School)

For six years as an enthusiastic site representative in Oxford
County, Cindys energy, commitment and willingness to include
the staff and students in the fundraising efforts are proof that
every school regardless of size can make a difference. As
a personal touch, Cindy attaches a United Way pin to a handwritten note to thank every individual who supports the
Bill McKinnon (Trustee, Oxford County)
Bills ongoing support of United Way Oxfords StairClimb is a
true testament to his commitment to supporting youth in our
community. He makes presentations at schools to motivate and
challenge students to get involved. He has volunteered at the
StairClimb and made a generous personal pledge to financially
support every participating student.

United Way Tax Tip

United Way issues charitable tax receipts that will reduce your federal and provincial income tax. For example:
Income Range

$43,561 or less

$43,562 to $87,123*

$87,124 and above

Your gift of

Approximate Total Tax Saving

Approximate Cost to You

Approximate Total Tax Saving

Approximate Cost to You

Approximate Total Tax Saving

Approximate Cost to You










































*Approximate total tax saving and cost to contributor at an income level of $75,000