Impact100 DC · 2025 Membership Form

CONTACT INFORMATION

Name *

First Name

Last Name

Email *

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MEMBERSHIP PLUS VIA INSTALLMENTS

The Membership Plus level of $1,130 includes $1,000 to fund the grant, $100 to help off-set operating costs of our all-volunteer organization, and $30 to cover credit card processing fees.

Amount *

$282.50 - Four monthly installments for a total of $1,130

Donation Schedule

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Preferred phone *

Would you like to be included in the Impact DC Membership Directory? *

This directory is for the exclusive use of our members and is not to be used for commercial or solicitation purposes. It is housed in password protected area of the Impact100 DC website under "Membership."

Please click yes to receive our monthly newsletter and other important updates. *

I WOULD LIKE TO VOLUNTEER!

I am interested in:

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 Referring Impact 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. Do you agree to this waiver?

Yes

No

2025 Membership Form - pay in installments

CONTACT INFORMATION

MEMBERSHIP PLUS VIA INSTALLMENTS

I WOULD LIKE TO VOLUNTEER!