Membership Form

Join Impact 100 / 2021-2022

Please use the below form to request information, join as a new member or renew an existing membership.  Note if you plan to pay for your dues from a donor advised fund please contact our organization to confirm our correct address (261 NW 13th Street Boca Raton, FL 33432) and tax ID number (82-4558049).

Basic Information

Participation

As a voting member, I am interested in actively participating as a volunteer on the following committee(s):

Membership Contribution

Payment Options

*For making my non - refundable, tax - deductible contribution to Impact 100 Palm Beach County for the 2021-2022 grant year: 

Recognition 

I grant Impact 100 Palm Beach County permission to publish my name and photo in the listing of members contained in the program for the Annual Awards Event and other promotional materials.

A copy of the official registration and financial information for Impact 100 Palm Beach County Inc., a Florida-based nonprofit corporation (Registration No. CH60185), may be obtained from the Division of Consumer Services by calling toll free 1-800-HELP-FLA (435-7352) within the state or visiting their website at www.freshfromflorida.com. Registration does not imply endorsement, approval, or recommendation by the state. Federal Tax ID Number: 82-4558049.

* Volunteer may be asked to submit a curriculum vitae and/or history of volunteerism specific to these committees

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please call our office at  (561) 336 - 4623