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Membership Profile Intake
First Name
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Last Name
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Email Address
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Home Mailing Address
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Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
*
Date of Birth
*
MM slash DD slash YYYY
Membership Level
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Impact100 Member ($1,100 by Check/Zelle or $1,135 by Credit Card)
Extra Impact Member ($1,300 by Check/Zelle or $1,335 by Credit Card)
Double My Impact Member ($2,200 by Check/Zelle or $2,235 by Credit Card)
Payment Method
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Check (Mailing address:6086 Lakeview Park Drive, Linden, MI 48451)
Credit Card through website
Note: Membership donations are due in full by March 31, 2025 and are non-refundable.
I want to be involved in the work of Impact100 Genesee County by serving on a committee - please contact me!
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