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Membership Form by Credit Card

To join for 2024 please complete the form below allowing you to pay by CREDIT CARD. Your $1,000 membership contribution goes in total to funding the grant. 110% Member contributions are highly appreciated and help defray essential operating expenses in this all-volunteer organization. All credit card payments include a $31 processing fee.

Contact Information

Name

First Name

Last Name

Verify Email

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone

Member Type

First Time Member

Renewing Member: You were a member last year

Rejoining Member: You were a previous member but not last year

Membership Level

110% Member - $1,000 going in full to the grant and $100 towards essential operating expenses.

Member - $1,000 going in full to the grant

Grant Contribution

$1,000

110% Member: Friend of Impact

$100 - Thank you! Your additional donation helps to defray our essential operating expenses.

Matching Funds

Do you plan to utilize matching funds through an employer or organization?

Yes

Which organization will match your membership fee?

I would like to make a contribution in addition to my membership

Yes

Contribution Type

To help with administrative costs

In honor of

In memory of

Gift of Membership to female friend or family member

In Honor Of/In Memory Of Name

Additional Contribution Amount. Add the following amount to my credit card charge:

I agree to be listed in annual report documents as a donor.

Yes

Photo Release

I grant to IMPACT 100 Greater Chesapeake, and its representative, permission to publish in print, electronic, or video format my likeness or image. I release all claims against IMPACT 100 Greater Chesapeake with respect to copyright ownership and publications including any claim for compensation related to use of materials.

Yes

Card Processing Fee

$31 - Credit Card Processing Fee. *If you wish to avoid this fee, please join by e-check or paper check.