Shared Membership Application - Impact100 Southern Indiana

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone*

Email*

Email Communication*

If you do not use email, check here
If you wish to be recognized as anonymous, please check here
Yes, please email me at the email address provided

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

Shared Member Name

First Last

Let us know who you are sharing your membership with!

I will act as the leader of the shared membership

Yes
No

DONATION OR MATCHING GIFT

Friend of Impact 100 Donation $

Matching Donation

Please include the contact information for the matching organization

PAYMENT

Membership*

Payment*

I will send a check to the address below
Bill me at the above address
I want to make installment payments - contact me to arrange payment details
I will pay via the link below

Consent

I understand that there is a processing fee for payment via PayPal/Credit Card. You can also provide this information over the phone to the Community Foundation Office by calling 812-948-4678. Payment in full must be received by July 1, 2021 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. Impact 100 Southern Indiana operates as a fund of the Community Foundation of Southern Indiana.

Full Name*

First

type your name to sign

Today's Date*

CAPTCHA