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2020 MEMBERSHIP FORM BY CREDIT CARD
PLEASE NOTE: PAY BY CREDIT CARD INCLUDES AN ADDITIONAL 3% PROCESSING FEE.
CONTACT INFORMATION
Name
First Name
Last Name
Email
*
Would you like to join the Impact100 DC mailing list?
*
This will allow you to receive our monthly newsletter and other important mailings.
select one
Yes
No
Address
Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Preferred phone
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
*
$1,130
-
Join as a Member Plus, with $1,000 going in full to the grant and $100 going to Impact DC essential operating expenses.
$1,030
-
Join as a full member
$
I WOULD LIKE TO VOLUNTEER!
Contact me for help with:
Events
Communications
Membership
Technology (website, database management)
Finance
Grant Review Committees
I would like to serve on a Grant Review Committee:
Health and Wellness
Education
Family
Arts and Culture
Environment
How did you hear about Impact100 DC?
From a current Impact100 DC member
From another Impact100 chapter member
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.
