One moment please...
2021-22 Membership Form - pay by eCheck

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

CONTACT INFORMATION
*

First Name
Last 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.
*
$
*

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

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

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?