First Name:
Middle/Initial:
Last Name:
Home Address:
Address Line 2
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
U.S. Minor Outlying Islands
Virgin Islands
Armed Forces Americas
Armed Forces Europe, the Middle East, an
Armed Forces Pacific
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip Code:
-
Zip Suffix
Phone:
Email:
Birth Date:
/
/
Neighborhood or Subdivision:
Golf or Social Club:
Seasonal/Fulltime
Dues and Payment Options
The annual, tax-deductible membership donation is $1,100. $1,000 goes directly to grant funding and $100 covers operating fees. Please submit your donation on or before your anniversary date in order to maintain a membership in good standing. Membership donations for the 2023-2024 grant cycle must be submitted by February 29th, 2024 in order to attend the annual meeting and/or vote for grants awarded in April 2024. You can submit your payment by:
Credit Card and ACH Bank Withdrawal - Online payments are subject to additional credit card processing fees. We kindly require that you opt to cover credit card and bank processing fees at check out in order to help keep our administrative costs as low as possible. 100% of donations and fees paid are tax-deductible.Check and Third Party Payments -If mailing a check, please note your membership will be considered active and renewed only when your donation payment is received. Select "Pay Later" on the next screen, make check payable to Impact 100 IRC, Inc., and mail it to:
Charitable registration number CH59372
To become a member of Impact 100, click the Membership checkbox below:
Membership Auto-Renewal
We are now offering the option to sign up for automated membership renewal for members making their payment by credit card or ACH withdrawal. Automatic renewal is a convenient way to ensure your membership always stays active. You will receive a reminder email shortly before your anniversary date and can opt-out at any time during the course of the year.
Additional Operations Donation
If you'd like to make an additional administrative donation to further assist in covering the operating fees associated with running Impact 100 of Indian River County, please hit submit below and then click on the shopping cart icon in the upper right hand corner of the payment form to add the amount of your additional donation. We thank you for your generosity!!!
