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Impact Fairfield County Membership Form

If possible, please consider paying by ACH Transfer. Help us reduce costs!

Membership in Impact FFC is contingent upon receipt of a $1,100 non-refundable donation and this signed form. This Annual Membership Fee includes a $1,000 contribution to our grant funding pool and a $100 donation to help cover our operating costs. Additional contribution options are detailed below in the payment section. Contributions are due by December 31st in order to participate on a Review Committee to evaluate nonprofit applicants. Returning Review Committee members can participate in the earlier stage of review if membership is renewed by November 15th.

I. Your Information
First Name:*
Last Name:*
Email Address:*
Type of Membership:*
New Membership
Membership Renewal
Are you willing to include your email and phone in a member directory?:
Yes
No
Address:
Address Line 2:
City:
State:
Zip:
Preferred Phone:

II. Help Us Understand Our Membership
How did you hear about Impact Fairfield County?:*
If a person, please share the name, so we can thank them!
Employer and/or Profession:
To help us understand the demographics of our membership, please select the race and/or ethnicity you self-identify with:
To help us understand the demographics of our membership, please select the age category you fit into:

III. Your Involvement
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 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/April) 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 request to participate on the same committee as another member (1 name please):
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 share my expertise or volunteer:
(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
Signature:*

IV. Your Contribution

Please consider paying by ACH Transfer. Help us significantly reduce costs! (Note, you will need to re-enter your information on that form.)
Payment Amount (Contribution):*

 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

2: 10th YEAR ANNIVERSARY GRANT (OPTIONAL):
In recognition of “A Decade of Impact”, this year Impact FFC will honor our past and current Grantees with 10th Year Anniversary Grants, which will be awarded at our Grant Awards Ceremony in May. Please indicate here if you would like to contribute to this special Grant Pool, which will be shared among all our 17 Grantees. 


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 (or you wish to apply yourself), please do so via our application form. 
$1,100 - covers cost of a membership and overhead
$550 - covers cost of 50% of membership and overhead
No scholarship contribution at this time

4: ABOVE & BEYOND FUND (OPTIONAL):
In addition to your Membership donation, members can provide an additional tax-deductible gift to build the current and future sustainability of Impact FFC. As an all-volunteer organization, we greatly appreciate additional donations as they help defray our operating costs and/or supplement our scholarship or grant funds. Your gift is a meaningful way to show support above and beyond all you already do.


TOTAL IMPACT FFC CONTRIBUTION:
Add amounts checked in 1, 2, 3 & 4 above and type in the total contribution to submit to Impact FFC.

Credit Card Information:
Card Type:

Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY (no slash)
Card ID (CVV2/CID) Number:
 [What is the Card ID?]
 

Impact Fairfield County is a nonprofit 501(c)(3) public charity and donations are tax deductible
to the fullest extent of the law.