Impact100 SRQ

Impact100 SRQ Member Scholarship Application

First Name *

Last Name *

Email *

Thank you for completing this application.

This program is intended for women who understand and believe in the mission and model of Impact100 SRQ who initially may not be able to fund a full Membership on their own. If possible, please consider alternate payment options (ex., payment plans, employer sponsorship) or paying in full if you are able, which would allow Impact100 SRQ to utilize funds available for those with the greatest need.

Please note: Scholarships are limited and based upon funds available. All that apply may not receive a scholarship. The Impact100 SRQ Board of Directors reserves the right to amend or suspend this program without notice at any time.

For more information, please contact Treasury at Treasurer@impact100SRQ.org

Street Address: *

City: *

State: *

Zipcode: *

Mobile Phone Number: *

What is your preferred method of communication? *
Select all that apply

Phone

Text

Are you a current member of Impact100 SRQ? *

Yes

What inspired you to become an Impact100 SRQ member? *

How did you hear about the scholarship program? *

Tell us about your involvement with civic or community service organizations. *

Tell us about any special skills or experience.

When possible, we encourage our scholarship recipients to take an active role in Impact100 SRQ by volunteering on a Committee, sharing your skill set by participating in a Workgroup, or giving a helping hand at our various chapter events. Each scholarship recipient will agree to participate in the annual voting process. How many hours per week would you be available to help with our mission? *
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Scholarship Options: *
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By submitting this application, I am indicating that I have read, understand and agree to comply with the requirements of this program. I am making a commitment to Impact100 SRQ, both with my financial contribution and volunteer time. My portion of the membership donation is based on the amounts listed in this application and are due in full by by the last day to join per the Impact100 SRQ website. I will have full membership privileges during the scholarship period, including the ability to be considered for a leadership position. *
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