Name
*
First Name
Last Name
Email
*
Type of Membership
*
Are you willing to include your email and phone in a member directory?
RENEWING MEMBERS: if all your contact information remains the same as last year, click yes below and move on to Section II.
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Preferred Phone
(###)
###
####
Employer and/or Profession:
To help us understand the demographics of our membership, select the race/ethnicity you self-identify with:
Please Select:
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Hispanic or Latino or Spanish Orgin
Other
To help us understand the demographics of our membership, please select the age category you fit into:
Please Select:
18-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
91-95
96-100
I would like to serve on a Grant Review Committee:
You will be sent a Conflict of Interest via email to complete.
RC Key Dates: Training 2/5 or 2/6, Mtg 1 on 2/26, Site Visits during 3/3-4/8, Mtg 2 on 4/9
I require or request virtual Grant Review Committee meetings:
This Review Committee will be capped; Although meetings will be virtual, site visits will remain in person.
I require or request night meetings:
Site visits (2-3 mtgs in March) may occur during the day due to non-profit schedules. Attendance is encouraged but not required to participate. Both other RC meetings will be in the evening.
I would like to serve on the Financial Review Committee:
You will be sent a Conflict of Interest via email to complete.
FRC Key Dates: Training 1/15, Mtg 1 on 2/25, Site Visits during 3/3-4/8, Mtg 2 on 4/9
I would like to volunteer or share my expertise:
An Impact Volunteer Coordinator will be in touch.
Confidentiality
*
I will not disclose confidential information acquired in connection with the work I do on behalf of Impact FFC. I agree not to share members’ contact information outside the membership. I understand that the membership list will be distributed to other Impact FFC members, and made available on our website and printed materials. I agree that my image may be used in photographs to promote Impact FFC via the website or other materials.
Conflict of Interest
*
To ensure a fully transparent grant selection process, I will disclose to the Impact FFC board of directors any potential conflict of interest that I may have with Impact FFC applicants. I understand that I may be asked to refrain from discussion on any topic where a potential conflict of interest arises. Also, I will not attempt to gain an advantage for or to persuade members to vote for a particular application.
Signature
*
Date
MM
DD
YYYY
THANK YOU!
Your membership form has been submitted. Your membership will be activated upon receipt of the membership fee. Our membership team will be in touch via email shortly.
Please mail your check to Impact Fairfield County, PO Box 7666, Greenwich, CT 06836
