Impact 100 Jersey Coast Scholarship Application: 2024 Membership Class

This program grants either a full or partial scholarship to cover the cost of one year's membership fees. In order to apply, please complete and submit this form for review by the scholarship committee. Thank you for your interest in becoming an Impact member!

Contact Information

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Verify Email

Yes, I'd like to receive the Impact 100 newsletter!

You are consenting to receive marketing emails from: Impact 100 Jersey Coast, P.O. Box 7989, Shrewsbury, NJ, 07702 United States, http://www.impact100jerseycoast.org. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact.

Preferred Phone

This is a cell phone and you may reach me via text.

Interest in Impact 100 Jersey Coast

Have you ever been a member of Impact 100 Jersey Coast or another Impact 100 chapter?

Yes

Have you ever been an Impact 100 Jersey Coast Scholarship recipient?

Yes

How did you learn about Impact 100 Jersey Coast?

Why do you want to be a part of our organization?

If you’re a prior member, what was your involvement - eg. attendance at events/volunteering etc (including during your scholarship year, if relevant)

In which facet of our organization would you like to participate, and what skills and experience would you bring to Impact 100?

Please include any additional commentary here for the consideration of the scholarship committee.

Scholarship Information

Requested Scholarship Amount

Note that scholarships may be granted for no more than two years to any one recipient. In the second year, members must apply again and the maximum amount contributed by Impact 100 Jersey Coast will be a partial scholarship of $550.

Partial: $550 contributed by member and $550 contributed by Impact 100 Jersey Coast.

Full: $1,100 contributed by Impact 100 Jersey Coast.

Partial Scholarship Donation Acknowledgement

I understand that if I am awarded a partial scholarship, Impact 100 Jersey Coast must receive my $550 (plus applicable credit card fees) Membership Donation by March 15, 2023.

Demographic Information

Date of Birth

(mm/dd/yyyy)

Occupation

Name of Employer

Race

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian of Other Pacific Islander

White

Ethnicity

Select one

Hispanic or Latino

NON Hispanic or Latino

I have reviewed and agree to abide by all policies and expectations as part of applying for scholarship funds.

If you become a scholarship recipient, we ask that you: communicate with your Impact100 representative throughout the year, vote at the Annual Meeting and consider volunteering in a specific role/position which could include any of the following: a "one & done" task, supporting a membership event, reviewing grant applications, and/or serving on one of our other committees.

Yes, I agree