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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
Email
*
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
Would you like to subscribe to the Impact100 DC email list?
*
This will allow you to receive our monthly newsletter and other important Impact100 DC updates.
select one
Yes
No
Address
Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Preferred phone
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.
