United Way Community Investment Committee: Volunteer Statement of Affiliations (LPUP)

Name: *

Company:

Title:

Address:

City/Town:

ZIP:

Email Address: *

Phone Number: *

NO, NEITHER MYSELF OR AN IMMEDIATE FAMILY MEMBER IS an officer, director, or employee of a United Way Partner Agency.

YES, EITHER MYSELF OR AN IMMEDIATE FAMILY MEMBER IS an officer, director, or employee of a United Way Partner Agency.

American Red Cross

ARCO

Boy Scouts of America, Louisiana Purchase Council

Boys & Girls Club of Northeast Louisiana

Children's Coalition of Northeast Louisiana

Christopher Youth Center

DART

Food Bank of Northeast Louisiana

Girl Scouts of Louisiana, Pines to the Gulf

Lincoln Council on Aging

LA Methodist Children & Family Services, Inc.

MedCamps of Louisiana, Inc.

Northeast LA Sickle Cell Anemia Foundation

Opportunities Industrialization Center of Ouachita (OIC)

Ouachita Council on Aging

Rays of Sonshine

The Salvation Army

St. Vincent De Paul

The Wellspring Alliance for Families

The Health Hut

Union Council on Aging

West Ouachita Senior Center

YMCA of Northeast Louisiana

Youth Services of Northeast Louisiana

Title at Organization if Affiliated with a United Way Partner or Grant Agency

Name (First, Last):

Date (Month/Day/Year):