Focus Group Sign Up

Thank you for your participation in a Focus Group. As you know Focus Groups are the heartbeat of our grant selection process. While the majority of your meetings will be held at this designated time, Site Visits are sometimes scheduled outside of your regular meeting time. We will do our best to honor everyone’s first choice of Focus Group, but it is important to keep numbers somewhat even to encourage a meaningful experience for everyone. Focus Group registration will close on June 1st. You will be contacted shortly after that by your Focus Group Chairs to get more information and your grant access.

Beth Shepherd & Amy Silvert
Grants Co-Chairs

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* 1. First Name

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* 2. Last Name

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* 3. Primary Email

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* 4. Cell Phone for text communication

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* 5. Have you served on an Impact 100 Focus Group before?

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* 6. Please select your FIRST choice of Focus Group

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* 7. Please select your SECOND choice of Focus Group

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* 8. Impact 100 Owensboro Conflict of Interest Statement

All members of Impact 100 must ensure that no personal or professional self-interest interferes with their work on behalf of Impact 100. All members must make sure that they do not have a conflict of interest when they are participating in Impact 100 work or business. A potential conflict of interest can arise in situations when a member, or someone in a member’s immediate family, would personally gain, either financially or professionally, from an action taken by Impact 100. For example, if an Impact 100 member would receive a job or financial gain if a certain non-profit receives an Impact 100 grant, then that member has a potential conflict of interest.

It is important for people to realize that simply serving on the board of a non-profit that has applied for or may apply for a grant from Impact 100 does not create a conflict of interest. It is only in the situation in which a member would personally profit from the grant being given to the non-profit that a conflict potentially arises.

If there is a real or potential conflict of interest, it is the member’s obligation to immediately notify the Board, in writing, of such conflict.

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* 9. Please choose one of the following two choices:

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* 10. I will advise the Board immediately, in writing, of any change regarding potential conflict of interest. Print name to acknowledge.

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* 11. Date

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