2022 Membership Form – Impact100 South Jersey

Contact Information

Name *

First

Last

Email Address *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Birth Year *

(Members must be 21 or older)

Preferred Phone *

Your preferred phone number is a: *

Membership Payment Options

Become an Impact 100 South Jersey voting member by donating $1,150.

Sign me up for 2021!

100% of your membership contribution is tax deductible. $1,000 will be used to fund Impact 100 South Jersey grants — $150 will help cover Impact 100 South Jersey administrative costs. Membership contributions are nonrefundable.

Payment Method *

Credit or Debit Card
Check
Donor Advised Fund

Installment options are only available for members who pay by credit card.

One Time Payment In Full or Installment Payments? *

Payment in Full
Installment Payments*

*MEMBERSHIP AMOUNT OF $1,150 MUST BE PAID IN FULL BY DECEMBER 15, 2020 TO BE CONSIDERED A MEMBER FOR THE 2021 GRANT YEAR. Payment options include 2, 3 or 4 equal monthly payments. Partial payments are non-refundable as these are charitable contributions for which you will receive tax documentation.

I'm interested in getting involved with:

HOST A MEMBERSHIP INFO SESSION: Introduce women you know to Impact100 SJ

YES! Please contact me to coordinate an information session.

GIVE THE GIFT OF IMPACT: Sponsor membership for a friend, family member or employee.

I will sponsor an Impact100 SJ Member

Name of Sponsored Member

Email Address of Sponsored Member

HELP CONNECT US WITH SPONSORS: Organizations interested in supporting local women's initiatives.

Contact me to chat about potential sponsors or contributors.

How did you learn about Impact100 South Jersey?

Word of Mouth
Social Media
Print Article
TV or Radio

Confidentiality, Conflicts of Interest & Photo Release I understand that confidential information may be acquired as a result of my association with Impact 100 South Jersey and that this information should not be disclosed. To insure a full transparent grant selection process, I will disclose to the Leadership Council any potential conflicts of interest I may have with grant applications or other Impact100 South Jersey business. Membership implies permission for Impact 100 South Jersey to use photographic, audiovisual and written works containing my image and name.

I agree with these terms *

I agree.

Almost Done

After you hit "SUBMIT," you will be directed to an online page where you can make your credit card contribution. You'll be given the option of choosing a one-time or installment payments.

If you choose to give through your Donor Advised Fund, please designate your 2021 contribution to the "Impact100 South Jersey Fund" at Community Foundation of South Jersey.

If you do not receive confirmation, please check your SPAM or JUNK folder.