One moment please...
2022-23 Membership Form - pay by paper check

Please make check payable to Impact100 DC. Mail your check to Impact100 DC, PO Box 40121, Washington, DC 20016

CONTACT INFORMATION
*

First Name
Last Name
*

*

MEMBERSHIP OPTIONS
We hope that you will join as a Member Plus. With every penny of your $1,000 donation going to the grant, we rely on those generous additional contributions to defray critical operating costs.
*
Fellowship Program and/or Additional Support

Our Fellowship Program sponsors women for membership who would like to be actively involved but currently lack the financial capacity to join.

Additional support contributions, again, are very welcome and allow us to continue to make improvements in the systems we use for grant review, databases, and the like.



*

*
*

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

*
*
This directory is housed in a password protected area of the Impact100 DC website. It is for the exclusive use of our members and is not to be used for commercial or solicitation purposes.
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?
Mail check to:

 Impact100 DC, PO Box 40121, Washington, DC 20016