We look forward to having you join us as a member! Please note that membership in Impact100 Philadelphia is conditioned upon receipt of a $1,150 non-refundable donation and this form. Contributions for the 2018 grants are due by December 1, 2017. All donations are tax deductible. Please fill out the sections below and click SUBMIT at the end of the form. All fields marked with an * are required to be completed for the form to submit properly. Contact InformationName*Please type your name below as you would like it to appear in the membership list. First Last Email*Email will be the primary way we will contact you. Please note, your email is required, however if there are no updates to your address or phone, please continue to Confidentiality and Conflicts of Interest section. Address Address - House Number & Street City State Zip Code Preferred Phone Mobile Home Work Preferred Phone NumberReferralPlease indicate whether you heard about us through a current member (including their name if possible), our website, social media, an email, or through another source. Thank you. Confidentiality & Conflicts of InterestConfidentiality & Conflicts of Interest*CONFIDENTIALITY: I will not disclose confidential information acquired in connection with the work I do on behalf of Impact100. I agree, each year I am a member, not to share members' names outside the membership. CONFLICTS OF INTEREST: To insure a fully transparent grant selection process, I will disclose to the Impact100 Philadelphia board of directors, each year I am a member, any potential conflict of interest that I may have with any Impact100 applicants. I understand that I may be asked to refrain from discussion on any topic where a potential conflict of interest arises. In addition, I will not attempt to gain an advantage for or to persuade other members to vote for any particular grant applicant. BY TYPING MY NAME BELOW, I acknowledge I have read and understood these statements.Payment InformationHow are you making your donation to Impact100 Philadelphia?*Mail a checkInstallment payment (Please contact me about this option)Credit card or PayPalPlease mail your check in the amount of $1,150 to: Impact100 Philadelphia P.O. Box 275 Wynnewood, PA 19096 Please select your donation amount:*Membership $1,185 (Please note: $35 was added to the $1,150 to cover the online processing fee.)Membership Other (If you'd like to make a donation of more than $1,185, choose this option.)Please Enter Your Donation Amount* Once you've entered your donation amount, click the "Submit" button to be taken to PayPal to complete your donation.Membership Fee Price: $1,185.00 Please Note: $35 was added to the $1,150 to cover the Paypal processing fee.