Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Type of Membership *

New Membership

Membership Renewal

Contribution *

$1,100 suggested fee to become a 110% member of Impact Fairfield County ($100 of your donation will support the cost of running ImpactFFC or be applied to additional grant funds)

$1,000 to only cover the cost of my membership to Impact Fairfield County, 100% of which will go to grants

I want to become a Member Plus+ and make an additional donation to total more than $1100 to support operating expenses and grants (you will enter amount in Step 2; regardless of additional donation amount, each woman receives one membership vote)

Payment Method

I will make payment by credit card

I will make payment via check, donor advised fund or foundation and a check will arrive separately

Member Sponsorship Program: I would like to provide the Impact FFC opportunity to a fellow member who offers great insight and involvement to our organization. Impact FFC is committed to giving a voice to all Fairfield County women and raising up critical diverse perspectives. Impact FFC will work to identify potential sponsorship recipients from our nonprofit grant recipient partners and from across Fairfield County, to encourage additional diverse perspectives and contributions to our membership. If there is someone you would like to nominate, please email membership@impactffc.org. All sponsorship recipients will be kept completely confidential.

*Any remaining sponsorship funding will roll over to the following grant year for additional sponsorships if not distributed entirely this year.

1/2 membership of $500

Full membership of $1,000

Full membership with overhead of $1,100

I would like to serve on a Review Committee

Review Committee

Financial Review Committee

I require evening Review Committee Meetings

Yes

No

I have not filled out the Volunteer Form and I would like to share my expertise or volunteer with:

Membership Recruitment/Engagement

Communications/Marketing/PR

Event Planning

Grants/Nonprofits

Technology

Other (An Impact member will reach out to you)

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.

I Agree

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.

I Agree

Date

MM

DD

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