Hazel 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.

MATCHING GIFT

Person Requesting Match

Name of Matching Organization

Dollar Amount of Match

Please include the contact information for the matching organization

PAYMENT

Membership*

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 July 1, 2024 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

type your name to sign

Today's Date*

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