NextGen Membership Form Join IMPACT 100 Owensboro Next Generation NEW FOR MARCH The join form is used to create user accounts and register new members. Step 1 of 2 - Member Information 50% Name(Required) First Last Current School Grade of Current School Year Address(Required) Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Member Email(Required) Enter Email Confirm Email Member PhoneThe primary phone number where you can be reached.Parent/Guardian Name(Required) First Last Parent/Guardian Email(Required) Enter Email Confirm Email Parent/Guardian Phone(Required) NextGen Membership(Required) Full Membership ($100) By submitting your membership, you are obligated to pay the $100 donation regardless of your involvement due to your membership being included in the grant total.Additional GiftYou may make a donation in addition to your membership fee. The Additional Gift will not be included in the grant, but rather will be used to offset operating costs. Choose your preferred payment option for Amount Due:(Required) Will Mail Check Will Pay Now by Credit Card Amount Due by CheckPlease make your check payable to Impact100 Owensboro and send to: Impact100 Owensboro Next Generation P.O. Box 1106 Owensboro, KY 42302 Full payment must be made by August 31.HiddenAmount Due by Credit Card PaymentProcessing fee 2.5% When you SUBMIT form you will be directed to our secure credit card processing system.Total Price: $0.00 PhoneThis field is for validation purposes and should be left unchanged.
