Heart Club and Rising Heart Recognition Form

Thank you for your generous support as a Heart Club member. We are grateful for your commitment to creating lasting change in our community.

Please note that plaque requests are processed on a quarterly basis. It may take some time before you receive your plaque, but we promise it’s on the way. If you have any questions in the meantime, feel free to reach out to us at unitedway@seuw.org

Donor ID Number

First Name:

Last Name:

Personal Email:

Work Email

Cell Phone:

Home Phone

Home Address:

Address

City/Town

State/Province

ZIP/Postal Code

Employer:

Combining With Your Spouse

Couples may combine their gifts to become members of the Heart Club, go up levels in the Heart Club, or reach Rising Heart level.

Yes, we would like to combine our gifts for Heart Club.

No, I do not wish to combine my gift.

Spouse Info (if combining)

Spouse First Name

Spouse Last Name

Spouse's Employer

Spouse's Pledge Will Be

Recognition Plaque

All Heart Club or Rising Heart givers may receive a plaque as recognition and thanks. The plaque includes space for year bars to be placed on every year you are a member.

Plaque Options

I already have a plaque, please send me a year bar.

I do not want a plaque.

I do not have a plaque and would like one engraved with my name stated as below.

Name to be engraved on plaque:

Recognition Listing

As a Heart Club or Rising Heart giver, your name will be listed with your company in our annual Heart Club booklet.

Publish my/our name:

Please do not publish my/our name.

Please publish my/our name as listed below.

Name to be listed in Heart Club booklet:

Communication Preferences

Please provide us with some information regarding your areas of interest and preferences. We will use this information to deliver you relevant information and updates.

Areas of Interest

Children

Vulnerable Adults

People In Crisis

Sign Me Up

Keep me informed about how my gift is making an impact

I would like information about volunteer opportunities

I agree to the terms of service.

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