Impact Team Intake Form

Thank you for your interest in serving on an Impact Team!

This form seeks to gather demographic and professional details while ensuring diversity across industries amongst impact teams and members.

PERSONAL INFORMATION

Full Name

Email Address

Age (please select a range)

18 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 and older

PROFESSIONAL INFORMATION

Current Occupation

Industry

Years of Experience

Please list any skills or expertise that are relevant to grant review

Please list any activities or involvements that could serve as a conflict of interest to this process (employment at a partner agency or related agency, board service, etc.)

I acknowledge that I have fully disclosed all agencies or charitable organizations to which I am presently involved that could pose a possible conflict of interest as defined within UWHC-referenced policies. (Please sign below)

I confirm that the information provided is accurate to the best of my knowledge.

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