Women's Giving Circle 2021 Membership Application

Women's Giving Circle Membership Form

Please fill in the fields, select area of interest, membership tier and submit payment once submission is complete.
Today's Date*

MonthDay Year
Name*

First Name Last Name
Organization
If joining under the name of an organization
Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail*
example@example.com
Phone Number:*

Area Code Phone Number
Membership Status*
What person, event or publication influenced your decision to join WGC?*
Which Committee(s) are you interested in joining? Please select all that apply. (Optional):
Area(s) of expertise or special skill sets (Optional):

Upload a headshot (Optional)
Next Steps:
*the examples given below are based on the minimum payment for the 'Advocate' Tier.*
1. In order for your application to be accepted, a minimum payment of 1/4 of your total pledge due upon submission.
2. Pledges may be paid in full or on a quarterly basis. (Ex. At the 'Advocate' tier, a second payment of $250 is due by December 31, 2021.)
3. Final payment is due by June 30, 2022.
By signing below, I agree to honor my committment of the "Membership Tier" contribution selected above to join the Women's Giving Circle. This includes an initial payment of a quarter of your selected pledge to the University of Maryland Capital Region Health Foundation.
Signature*

Clear
By clicking the "Pay Now" button you are submiting your online application and payment. If you are not prepared to pay at this time, please click the "Save" button to save your application. Once we are in receipt of your payment, we will contact you regarding your Membership. Thank you!
PLEASE REMEMBER TO SUBMIT YOUR MINIMUM MEMBERSHIP COMMITMENT.

Checks should be made payable to UM Capital Region Health Foundation (NOTE: Women's Giving Circle) and mailed to: Attention - Tiffini Gillespie 7300 Van Dusen Rd, Laurel, MD 20707. Or, you may make an online payment at https://bit.ly/donatewgc
Desired Pledge Amount
Please type the desired dollar amount above.

MEMBERSHIP TIERS*

1000 for $1000 Campaign --- (make a payment selection below) $ Free

By selecting this option you are committing to a 1000 for $1000 Campaign contribution.

1000 for $1000 Campaign

CHECK PAYMENT ONLY---(minimum payment amount required ) $ Free

By selecting this option you are committing to making a payment by check mailed directly to the foundation.

Visionary 10,000 and above---(minimum required payment)$2,500.00

By selecting this tier you are committing to making a payment of $2,500 today.

Innovator $5,000 - $9,999---(minimum required payment)$1,250.00

By selecting this tier you are committing to making a payment of $1,250 today.

Patron $2,500 - $4,999---(minimum required payment)$625.00

By selecting this tier you are committing to making a payment of $625 today.

Advocate $1000 - $2,499---(minimum required payment)$250.00

By selecting this tier you are committing to making a payment of $250 today.

Total $0.00

In accordance with IRS regulations, UM Capital Region Health Foundation is a 501(c)(3) organization. For your records our EIN Number is 52-1299547. Your donation is tax-deductible in full, unless otherwise stated in this acknowledgement. Please consult your tax professional for further guidance on your donation. Please advise if you wish to opt out of future solicitations by contacting the Philanthropy office at umcapitalfoundation@umm.edu
7300 Van Dusen Rd. Laurel, MD 20707 | www.umcapitalregionfoundation.org | umcapitalfoundation@umm.edu
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Women's Giving Circle Membership Form