Impact Fairfield County Scholarship Application Form

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

For 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

(###)

###

####

Are you applying for a full or half scholarship? *

Full, $1100 scholarship

Half, $550 scholarship (Impact FFC covers $550, member contributes $550)

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:

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