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Membership Form by e-check

To join for 2024 please complete the form below allowing you to pay by e-check Your $1,000 membership contribution goes in total to funding the grant. 110% Member 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.

Contact Information

Name

First Name

Last Name

Verify Email

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone

Member Type

First Time Member

Renewing Member: You were a member last year

Rejoining Member: You were a previous member but not last year

Amount

$1,100 - 110% Member, with $1,000 going in full to the grant and $100 going to Impact Greater Chesapeake essential operating expenses.

$1,000 - Member, with $1,000 going in full to the grant.

Matching Funds

Do you plan to utilize matching funds through an employer or organization?

Yes

Which organization will match your membership fee?

I would like to make a contribution in addition to my membership

Yes

Contribution Type

To help with administrative costs

In honor of

In memory of

Gift of Membership to female friend or family member

In Honor Of/In Memory Of Name

Additional Contribution Amount. Add the following amount to my e-check:

I agree to be listed in annual report documents as a donor.

Yes

Photo Release

I grant to IMPACT 100 Greater Chesapeake, and its representative, permission to publish in print, electronic, or video format my likeness or image. I release all claims against IMPACT 100 Greater Chesapeake with respect to copyright ownership and publications including any claim for compensation related to use of materials.

Yes