Enrollment is open for 2017. New members may immediately participate in Impact100 events
and will be eligible to vote for the grant recipient in the Fall of 2017.
Arts & Culture
Education
Environment & Recreation
Family
Health & Wellness
2017 Membership and Donation Form
☐ Returning member
☐ New member
☐ Friend of Impact100
Member Information
Name:
Date:
I learned about Impact100 from:
Street Address:
City, State, Zip:
E-mail Address:
Phone number:
I am interested in volunteering in the following areas (optional): ☐ Membership Recruitment
☐ Event Planning
☐ Public Relations/Media
☐ Non-profit recruitment
☐ Member Communications
☐Volunteer Coordination
☐ Grant Review
☐ Finance/Tax Requirements
☐ Misc/Other Professional Expertise:
☐ I don’t have time to volunteer this year, so I will include an additional donation for administrative expenses (optional - see below).
Membership - Due by March 31, 2017
$1,000 annual membership provides voting rights for one woman.
☐ Enclosed is a check for $1,000 for an individual one year membership.
☐ I want to join the 110% Club! Here’s my check for $1,100 which includes my membership plus $100 for expenses.
☐ Membership dues enclosed. An additional $_____________ is included to help with administrative expenses.
☐ Enclosed is a check for $500. I applied to my company: ___________________________________ for a match of $500.
☐ My sponsor ____________________________________________________________ has submitted my membership dues.
Friend Donations
While voting rights are only given for full membership dues of $1,000, Friend donations are critical to the success of Impact100
Oakland County because 100% of membership dues go to grant giving. The Board of Directors has the discretion to use any
donations other than full membership for administrative expenses or as grant money.
☐ I wish to become a Friend of Impact100 and help with administrative expenses with my financial donation of $ _________________
☐ I wish to become a Friend of Impact100 and help with administrative expenses with my in-kind donation of ____________________
☐ I wish to sponsor: _______ _____________________________________________ with my donation of $ _______________________
☐ I wish to give a gift in honor/memory of _________________________________ with my donation of $___________________
For gifts, please send acknowledgment to _____________________________________________________________________
Please make checks payable to Impact100 Oakland County and mail to 33717 Woodward Avenue, #505, Birmingham, MI 48009
Impact100 Oakland County is a 501(C)(3)under federal law and all contributions are tax deductible.
[email protected]
Membership implies permission to use photographic, audiovisual and written works containing images and names from Impact100 forums.
Conflict of Interest / Confidentiality Form
Conflict of Interest Policy
Every Impact100 Oakland County member is required to sign a “Conflict of Interest” form when she becomes
a member. Because it is an expectation that a member will not personally benefit from a grant allocation, a
member may not vote for a grant recipient that will benefit her or her family. In the event a member
discloses a conflict of interest, the issue will be reviewed prior to the Annual Meeting by two or more
officers of the board of directors. If the member casts her ballot contrary to the decision of the officers of
the board, her vote will be disqualified.
Conflict Of Interest
As a member of Impact100 Oakland County I ______________________________________agree to abide
by the conflict of interest policies of the organization. I agree to disclose all conflicts of interest as they arise
or become known.
Signature
Date
If submitting electronically, please electronically sign below:
Enter Your First and Last Name:
Date:
I understand that checking this box constitutes a legal signature confirming that I acknowledge and
agree to the above Terms of Acceptance.
Confidentiality
I will hold in confidence all confidential proceedings and discussions of Impact100 Oakland County.
Signature
Date
If submitting electronically, please electronically sign below:
Enter Your First and Last Name:
Date:
I understand that checking this box constitutes a legal signature confirming that I acknowledge and
agree to the above Terms of Acceptance.
www.impact100oaklandcounty.org
33717 Woodward Avenue, #505, Birmingham, MI 48009
[email protected]