Impact 100 Jersey Coast · Teen Impact Membership Form

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Member Name *

First Name

Last Name

Member Email *

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Birthday *

(mm/dd/yyyy)

Member Mobile

High School Name *

If "other" High School Name (please spell out)

Year of High School Graduation? *

Do you know a member of Impact 100 Jersey Coast (adult organization)?

First Name

Last Name

Relationship

Parent Name *

First Name

Last Name

Parent Email *

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How did you learn about Teen Impact?

Why do you want to join Teen Impact?

Membership Donation *

$125

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian of Other Pacific Islander

White

Some Other Race

Ethnicity

Hispanic or Latino

NOT Hispanic or Latino

Your donation of $125 ($100 for grantmaking; $25 will cover membership activities, CFNJ* fund management fee and processing fees) will be processed today.

Teen Impact Jersey Coast operates under The Community Foundation of New Jersey which is a nonprofit 501(c)(3) public charity, and all donations are tax-deductible to the fullest extent of the law.

Code of Conduct, Confidentiality Agreement & Photo Release *

By participating in Teen Impact, member consents to being photographed and/or filmed and consents that your image, voice, and likeness may be used by the Organizer, without compensation to member, for any purpose in any media (now known or hereafter devised) throughout the world in perpetuity, including but not limited to use in photographs, videotapes, CDs, DVDs, broadcast, telecast, live streams, podcast, webcast, recordings, motion pictures, commercial advertisement, promotional materials, and/or any other record of the program’s activities. Member understands that all copyright rights in the images shall be owned by Organizer in perpetuity and waives any inspection or approval rights.. I will adhere to the Code of Conduct on the website. I will not disclose confidential information acquired in connection with the work I do on behalf of Teen Impact Jersey Coast. I agree not to share members’ names outside the organization and understand that the membership list will not be printed and distributed to other members.

I agree to all terms outlined in the Teen Impact Jersey Code of Conduct, Confidentiality Agreement & Photo Release.

After you hit the submit button you will be prompted to enter your payment info. Please enter the name of the account holder. *

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Teen Impact Membership Form

We are a passionate group of young women (High School Age), who are committed to making a difference in our community, by giving grants to local charities and non-profits that are focused on youths in need.

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