Membership Application - Impact100 East Bay

Member Type

First time member
Renewing member: I was a member last year
Rejoining member: I have been a member previously, but was not for the 2021 cycle

First Name*

Last Name*

Address*

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

Email*

Phone*

Preferred Phone Number*

Mobile
Home

Membership Level*

100% of the first $1000 of every donation will be donated to fund the 2022 grant. Select one option below.

Member Champion ($1,500 or more) Your gift of $1,500 or more will help fund operational and/or scholarship funds.
Member Plus ($1,100 - $1,499) with amount in excess of $1000 used to offset operating expenses of our all-volunteer organization.
Member ($1,000) 100% of this donation will be applied to the 2022 Impact Grant(s).

Enter Full Donation*

Member Champion Donation Option*

$500 of my donation goes to the scholarship fund with any remaining to operating expenses
Use the funds where they are most needed

I am interested in volunteering

If a member referred you, please include her name here:

Company Matching

If your company matches charitable donations, please list the company name here:

Comments

Please send us any feedback to improve your experience in the box below.

By submitting below, I am allowing Impact 100 East Bay to use my name and image in photographic, audiovisual, and written works. To withdraw this consent please send a message to info@impact100eastbay.org with your request.

Paying Method*

Pay by credit card
Pay by e-check
Pay by paper check

This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes.

Pay by Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Please note that a 3.5% convenience fee will be added to your donation when you pay by credit card.

eCheck

Name on Account Bank Name Routing Number Account Number Account Type

Make checks payable to Impact 100 East Bay. Submit the form online and mail your check to Impact100 East Bay, PO Box 2889, Castro Valley, CA 94546-0889