One moment please...
2022-23 Membership Form - pay in installments

We offer installment payments for those joining at the Member Plus Level ($1,100) no later than September 30, 2022 and paying via PayPal. The total payment of $1,130 includes $1,000 for the grant, $100 for operating costs, and $30 in PayPal processing fees. To join, please complete the form below authorizing payment in four monthly installments of $282.50.

CONTACT INFORMATION
*

First Name
Last Name
*

*

MEMBERSHIP PLUS VIA INSTALLMENTS
The Membership Plus level of $1,130 includes $1,000 to fund the grant, $100 to help off-set operating costs of our all-volunteer organization, and $30 to cover credit card processing fees.
*
Monthly
*

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
*

*
This directory is for the exclusive use of our members and is not to be used for commercial or solicitation purposes. It is housed in password protected area of the Impact100 DC website under "Membership."
*
I WOULD LIKE TO VOLUNTEER!

First Name
Last Name
*
Media Release: I hereby grant Impact100 DC, and its respective agents and assigns, the unrestricted right to use images of me from Impact100 DC events (both live and virtual) for trade, marketing, and other purposes without restriction and without my inspection or approval. I hereby release Impact100 DC and its respective agents from any legal claims or financial liability associated with such use. Do you agree to this waiver?