Membership Application - Impact100 Southern Indiana

Name*

First Last

If you wish to be recognized as anonymous, please check here

Address*

Street Address Address Line 2 City State Zip Country

Preferred Phone*

This number can receive texts

Email

Email Communication*

If you do not use email, check here
Yes, please email me at the email address provided

Email is our main form of communication for all member information, dates, etc.

GIFT MEMBERSHIP

Gift of Membership

This is a gift of a membership to a female family member or friend

Please fill out the gift recipient's personal information below.

Gift Recipient's Name

First Last

Gift Recipient's Address

Street Address Address Line 2 City State Zip Country

Gift Recipient's Preferred Phone

Gift Recipient's Email

Email Communication

If they do not use email, check here
Yes, please email them at the email address provided

Email is our main form of communication for all member information, dates, etc.

MATCHING GIFT

Matching Gift

An organization is matching this gift.

Please fill out the gift recipient's personal information below.

Person Requesting Match

Name of Matching Organization

Matching Organization's Address

Street Address Address Line 2 City State Zip Country

Matching Organization's Preferred Phone

Matching Organization's Email

Dollar Amount of Match

PAYMENT

Membership*

Please select your membership type.

Payment*

I will mail a check to Impact100 Southern Indiana, 4510 Charlestown Rd, Suite 400, PMB 218, New Albany, IN 47150
Bill me at the above address
I wish to make installment payments of $250 or $500
I will pay via the PayPal link on the next page

Consent

I understand that there is a processing fee of 2.5% for payment via PayPal/Credit Card. Payment in full must be received by June 1, 2027 to be recognized as a member and to receive a vote in the annual award celebration. Funds are non-returnable. I recognize this form is for Impact 100 Southern Indiana, which supports nonprofits in Clark, Floyd, and Harrison counties in Indiana.

Full Name*

First Last

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Today's Date*

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