Name *

First Name

Last Name

Type of Membership *

New Membership

Membership Renewal

Are you willing to include your email and phone in a member directory?

Yes

No

RENEWING MEMBERS: if all your contact information remains the same as last year, click yes below and move on to Section II.

Yes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone

(###)

###

####

I would like to serve on a Grant Review Committee:

You will be sent a Conflict of Interest via email to complete. RC Key Dates: Training 2/5 or 2/6, Mtg 1 on 2/26, Site Visits during 3/3-4/8, Mtg 2 on 4/9

Yes

No

I require or request virtual Grant Review Committee meetings:

This Review Committee will be capped; Although meetings will be virtual, site visits will remain in person.

Yes

No

I require or request night meetings:

Site visits (2-3 mtgs in March) may occur during the day due to non-profit schedules. Attendance is encouraged but not required to participate. Both other RC meetings will be in the evening.

Yes

No

I would like to serve on the Financial Review Committee:

You will be sent a Conflict of Interest via email to complete. FRC Key Dates: Training 1/15, Mtg 1 on 2/25, Site Visits during 3/3-4/8, Mtg 2 on 4/9

Yes

No

I would like to volunteer or share my expertise:

An Impact Volunteer Coordinator will be in touch.

Membership Recruitment/Engagement

Communications/Marketing/PR

Event Planning

Grants/Nonprofits

Technology/Website/Social Media

Diversity, Equity, Inclusion & Belonging

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

YYYY

I will pay by check, donor advised fund or foundation *

Yes

1. MEMBERSHIP: *

$1,100 Membership Fee: $1,000 will fund our Impact FFC Grant Awards and $100 will be contributed to help cover membership overhead.

$1,100

3. MEMBER SCHOLARSHIP FUND (OPTIONAL):

Impact FFC is committed to giving a voice to all women of Fairfield County. Our Member Scholarship Fund helps ensure this by removing barriers and welcoming critical diverse perspectives, insight and involvement in our organization. All scholarship recipients are kept completely confidential. If there is someone you would like to nominate, please email membership@impactffc.org. If you wish to apply yourself, you may use the application form found on our JOIN NOW page.

$1,100 - covers cost of a membership and overhead

$550 - covers cost of 50% of membership and overhead