One moment please...
2021-22 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
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.
*

Any additional amount helps cover operating expenses.
*

Total amount of your check (ex: Member Plus + 100 extra donation = 1200). Please enter numerals only.
*

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.
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