Impact100 DC · 2021-22 Membership Form

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2021-22 Membership Form - pay by eCheck

To join, please complete the form below allowing you to pay by electronic check.

CONTACT INFORMATION

Name

First Name

Last Name

MEMBERSHIP OPTIONS

Your $1,000 membership contribution goes in total to funding the grant. Member Plus contributions of $1,100 as well as any additional amount you enter in the third, customized option are highly appreciated and help defray essential operating expenses in this all-volunteer organization.

Amount

$1,100 - Join as a Member Plus, with additional funds going to essential operating expenses.

$1,000 - Join as a full Member

Are you a new or returning member of Impact100 DC?

New Member in 2021

Renewing Member

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Preferred phone

Please click yes to receive our monthly newsletter and other important updates.

Would you like to be included in the Impact DC membership directory?

This directory will be for the exclusive use of our members and is not to be used for commercial or solicitation purposes.

Would you like your photo included in the Impact DC membership directory?

Providing your photo

If you have previously provided a photo to the Impact100 DC membership team, you are all set!

If you have not provided a photo or would like to provide a new one, please email your photo to membership@impact100dc.org or to anyone on the Impact100 DC Board.

I WOULD LIKE TO VOLUNTEER!

Contact me for help with:

Events

Communications

Membership

Technology (website, database management)

Finance

Grant Review Committees

How did you hear about Impact100 DC?

From a member of Impact100 DC

From a member of another Impact100 chapter

News article

Social media

Word of mouth

Name of Impact100 DC member

First Name

Last Name

WAIVERS

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.