Gen Impact Accelerator Registration First Name*Last Name**Email* PhoneAddress* Country*AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe OrganizationDietary restrictionsUpload your headshot here:Upload your bio here:If you do not have your bio or photo readily available, you can also email them to firstname.lastname@example.orgProgram Questionnaire Before you begin your journey with us, please fill out the below questionnaire to help us learn more about you and your goals. ExperienceWhich of the following do you consider yourself?PhilanthropistSocial InvestorSocial EntrepreneurImpact InvestorOtherHow would you characterize your role as a social/philanthropic investor?It’s a hobbyIt’s a part-time occupationIt’s a full-time professionOn average, how many days per month do you spend on this work?When did you begin doing this work?201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945Network The Gen Impact Accelerator is built around peer learning and exchange. After the course, you will become a part of the 21/64 and TPW network that includes access to curated educational experiences about giving and related issues concerning network members. There is a wealth of knowledge and experience held within the network and we encourage you to share your own expertise and seek out assistance from others.What are you most looking to receive from other attendees and the larger peer network?What expertise are you able to provide to other network members?Are you interested in joining a small peer group that meets regularly in your area?YesNoRegistration Payment The following expenses are not included in the registration fee: Accommodation in Napa, CA Flight/Travel Meals not affiliated with program sessions Personal/miscellaneous expenses If you have any questions, please feel free to contact Andine at email@example.com.Registration Fee*$2,500Form of Payment*Credit CardCheckBank Wire TransferTotal $0.00 Check Payment: If you prefer to pay by check please mail to: 21/64 445 Park Avenue, 16th Floor New York, NY 10022 Attn: Barbara TaylorCancellation We understand life happens. If you cancel more than 60 days prior to a scheduled course, your registration will be refunded in full. If your cancellation is 30-60 days prior your registration be refunded 50%. All cancellations within 30 days of the course date are nonrefundable. We will try to take into account any extenuating circumstances that result in cancellation and may allow your fee to be applied to a future training within 12 months.Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.