NextGen Membership Form

Step 1 of 2 - Member Information

Name*
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Current School
Grade of Current School Year
Address*
Street Address Address Line 2 City State ZIP Code
Member Email*
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Member Phone
The primary phone number where you can be reached.
Parent/Guardian Name*
First Last
Parent/Guardian Email*
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Parent/Guardian Phone*

P. O. Box 1106
Owensboro, KY 42302

270-929-7429
board@Impact100owensboro.org

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