Impact 100 Membership Form

Membership Contribution - all membership contributions are due by June 1, 2019. *

Individual Member - $1,100 and have one vote Circle Member- $550 and will join one other for one vote Circle Member - $275 and will join with 3 others for one vote

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: *

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) *

Check - made payable to PCF Virginia, Memo: "Impact 100", Mail to: 48 W. Queens Way, Hampton, VA 23669 Credit Card - 2% will be added to cover the credit card processing fee. Please call Jennifer Wells/PCF at 327-0862 to provide card information.

Types of Funds - Impact 100 Membership Form

2018 - 2019 Online Membership Form