North Range Behavioral Health Employee Campaign Step 1 – Please fill in your informationProgram(Required)Accounting: 1Billing: 1ACT: 2Administration: 3Adult Outpatient Program: 4JBBS: 4Adult Recovery Program: 5Hope/Access 6Learning and Culture: 7Marketing: 7SESS: 7Quality Improvement: 7CO RESPONDER: 8Counseling Center at Carbon Valley: 9Counseling Center at Fort Lupton: 9Counseling Center at West Greeley: 10CSS: 11Detox Services: 12Respite: 12Data/EHR: 13Information Technology: 14Facility Services: 15Youth & Family in Home: 16Food Service: 17Frontier House: 18IPS: 18HIPPY: 19Safe Care: 19Parents as Teachers: 19Human Resources: 20Credentialing: 20Integrated Healthcare: 21Specialize Woman's Services: 21Intensive Youth & Family: 22TACT: 22Kinnick: 23Maxwell Center: 23Stanik: 24Recovery Support Services: 24Medical: 25Peer Counselors: 26School Based Services: 27Support Staff, Supervisor Delgado: 28Support Staff, Supervisor Herrera: 29Support Staff, Supervisor Schledewitz: 30Support Staff, Supervisor Edgerly: 30Support Staff, Supervisor Trujillo: 31True North: 32CRT: 33ICC: 33WINGS: 34Early Childhood Team: 35Youth & Family OP: 36First(Required)Last(Required)Preferred Email(Required) Email Type Work Personal Preferred Phone(Required)Phone Type Cell Work Personal Home Address(Required) Street City State Zip Date of BirthWhat year did you begin supporting United Way?My investment will be combined with my spouse/partnerMy spouse/partner works atPlease list my/our name for recognition as:I /we wish to remain anonymous in publications yes, I want to be anonymous What inspired you to give today?Step 2 – Donation OptionsChoose how you would like to contribute Payroll Deduction Credit Card – One Time Credit Card – Monthly Credit Card – Quarterly Credit Card – Annually Bill me ($50 minimum) Check (made payable to United Way) I do not wish to give at this time I authorize the company to deduct the following amount per pay period.Total Payroll DonationThank you for your consideration & response. If you change your mind, please contact us at 970-353-4300. For your convenience, please give your check to your company campaign coordinator as you submit your pledge online. Thank youCharge my credit card this amount Charge my credit card this amount every month Charge my credit card this amount every quarter Charge my credit card this amount every year Credit CardCard Details Cardholder Name My total donationBilling Start Date MM slash DD slash YYYY Bill me: Monthly Quarterly Yearly (one-time) Please make this an ongoing gift that will automatically renew annually Yes, renew my gift Step 3 – Tell us how you want your investment to helpI want to Invest in the Greatest Area of Need Yes, direct to the greatest need OR Specific Initiative Area Reading Great by 8 Thrive by 25 Weld’s Way Home Aging Well Connecting Weld OR Available Tax Credits 50% Colorado Child Care Contribution Credit 25% Homeless Contribution Tax Credit ($100 minimum) OR Specific Designation Specific nonprofit/agency – $50 minimum. An adminstrative fee will be deducted.Please fill in name and address below Specific Designation: Nonprofit/Agency Name and AddressI authorize access for my company campaign coordinators to see this gift information(Required) Yes No Δ
