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Types of Funds - Impact 100 Membership Form
Printable Form
2019-2020 - Year 5: Online Membership Form
*
Indicates required field
Name
*
First
Last
New Member
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Yes
No
Email
*
Phone
*
Phone Number
*
Membership Contribution - all membership contributions are due by June 1, 2020.
*
Individual Member - $1,100
Circle Member- $550 I am a Circle Leader
Circle Member - $367 Circle Member
Circle Member - $275 Help me find a Circle
I am interested in hosting a Little Join
For Circle Members
*
Please include me with a Circle and notify me of my Circle Leader
I have a Circle Leader
Circle Leader Name
*
Participation - As a voting member, I am also interested in actively participating as a volunteer on the following Grants Committee:
*
Grants
Membership
Newsletter
Social Media
Events
Publicity
Recognition
*
I grant permission to Impact 100 Greater Peninsula and the Peninsula Community Foundation to use my name and photo on electronic and printed donor lists, website and other promotional materials.
I wish to remain anonymous for purposes of public recognition
I agree that my email will be used as the primary means of communication only for Impact 100 volunteers and Peninsula Community Foundation staff.
Payment Options - (Choose One)
*
Will mail in Check - made payable to PCF Virginia, Memo: "Impact 100", Mail to: 48 W. Queens Way, Hampton, VA 23669 by June 1, 2020
Credit Card - 2% will be added to cover the credit card processing fee. Please call Jennifer Brambley/PCF at 327-0862 to provide card information.
Please contact me about making monthly payments
Please contact me about making a donation other than the above options
Address
*
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City
State
Zip Code
Country
Comments
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Type full name for Signature
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Submit