Impact100 DC · 2024 Membership Form

CONTACT INFORMATION

Name

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First Name

Last Name

Email

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Verify Email

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Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Preferred phone

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MEMBERSHIP OPTIONS

We hope that you will join as a Member Plus. With every penny of your $1,000 donation going to the grant, we rely on this additional contribution of $100 to help defray critical operating costs.

Select Membership Level

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1100 - Member Plus

1000 - Member

Would you like to make an additional donation?

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Select "Yes" to see options to donate to our operating budget, Fellowship program, or to sponsor a member.

Yes

No

OPTIONS FOR ADDITIONAL SUPPORT:

Operating Fund, Fellowship Program, Member Sponsorship

With additional operating support, there is much more that we can do, from upgrades in technology to member events and more. Will you consider increasing your member-plus support?
Click HERE to read more about our Fellowship Program, which provides opportunities for young professionals to participate in philanthropic work and adds to the diversity of voices in our community.
Do you have a friend, relative, or colleague you would like to sponsor for membership?

Additional support for Impact100 DC's operations

Fellowship Program Contribution

I would like to sponsor a member

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Yes

No

Member Sponsorship Amount

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$1130 - Member Plus Scholarship

$1030 - Member Sponsorship

Name of sponsored member

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First Name

Last Name

Email address of sponsored member

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Verify Email

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TOTAL CHECK AMOUNT

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

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

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

I WOULD LIKE TO VOLUNTEER!

I am interested in being involved with:

Events

Communications

Membership

Technology (website, database management)

Finance

Grant Review Committee

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 Impact100 DC member:

First Name

Last Name

WAIVERS

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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

Mail check to:

Impact100 DC, PO Box 40121, Washington, DC 20016

2024 Membership Form - pay by paper check

CONTACT INFORMATION

MEMBERSHIP OPTIONS

I WOULD LIKE TO VOLUNTEER!