Make an IMPACT

Thank you for helping power positive change in our community. To complete your 2022-2023 membership for Impact the Palm Beaches, please fill out the form below hosted by our fiscal agent and community partner, the Town of Palm Beach United Way.

If you wish to pay in installments (monthly or quarterly), or make a pledge (a promise to pay at a later date), please call the Town of Palm Beach United Way at 561-655-1919 – they will be happy to assist you.

Please also call the United Way office if you are paying through a private foundation or donor advised fund.

Membership *

2022-2023 Annual Membership ($1,100 is tax deductible) - $ 1,100.00

($1,000 grant pool and $100 administrative fee)

Total Amount

Impact Profile

Legacy Membership

I wish to become a Legacy member (pledge to commit to membership for this year and the next two years)

First Name *

Last Name *

Home Address *

Community

Home City *

Home State *

Zip *

Personal Email *

Personal Cell *

Company

Job Title

Industry

Company Address

Company City

Company State

Company Zip

Company Phone

Company Email

Preferred Phone Number *

Personal Company

Preferred Email Address *

Personal Company

Birth Date (Month and Day)

I was referred by

I would like my name to appear as *

Sponsorships

I am interested in sponsorship opportunities. Please contact me.

Credit Card

Card Type

Card Number

Security Code

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

THE TOWN OF PALM BEACH UNITED WAY MEETS ALL REQUIREMENTS SPECIFIED BY THE FLORIDA SOLICITATION OF CONTRIBUTIONS ACT. A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL FREE WITHIN THE STATE (1-800-435-7352). REGISTRATION DOES NOT IMPLY ENDORESEMENT, APPROVAL OR RECOMMENDATIONS BY THE STATE. FLORIDA REGISTRATION NUMBER 710843, FEDERAL ID NUMBER 59-063-7885. THE TOWN OF PALM BEACH UNITED WAY RECEIVES 100% OF EACH CONTRIBUTION. THIS INFORMATION WILL BE USED ONLY BY THE TOWN OF PALM BEACH UNITED WAY AND WILL NOT BE DISCLOSED TO OTHER PARTIES.