Membership inquiry form

Completing this membership inquiry is the first step in becoming a village member. After submitting this inquiry form, a membership volunteer will contact you to discuss scheduling Villager Introduction meeting.

The initial meeting may include:

Completing initial member home visit and interview
Answering any questions that you might have
Reading and signing a member Agreement
Paying your annual membership fees

First name

Last name

Phone

Cell phone

Date of birth

Marital status

Gender

Number

Street

City

State

Zip Code

Available Membership Options

8. FLEX MEMBERSHIP, INDIVIDUAL, 25.00 PER MONTH, UNLIMITED SOCIAL ACTIVITIES, UP TO 4 SERVICES A YEAR.: $25.00 per month for 12 months

7. FLEX MEMBERSHIP, HOUSEHOLD, 25.00 PER MONTH, TWO PEOPLE IN SAME HOUSEHOLD, UNLIMITED SOCIAL ACTIVITIES, UP TO 4 SERVICES PER YEAR.: $25.00 per month for 12 months

4. FULL MEMBERSHIP, INDIVIDUAL, 45.00 PER MONTH, UNLIMITED SOCIAL ACTIVITIES, UP TO 12 SERVICES PER MONTH: $45.00 per month for 12 months

3. FULL MEMBERSHIP, HOUSEHOLD 45.00 PER MONTH, TWO PEOPLE IN THE SAME HOUSEHOLD, UNLIMITED SOCIAL ACTIVITIES, UP TO 12 SERVICES PER MONTH: $45.00 per month for 12 months

6. FLEX MEMBERSHIP, INDIVIDUAL, 275.00 FOR 12 MONTHS, UNLIMITED SOCIAL ACTIVITIES, UP TO 4 SERVICES PER YEAR: $25.00 per month for 12 months

5. FLEX MEMBERSHIP, HOUSEHOLD, 275.00 FOR 12 MONTHS, TWO PEOPLE IN THE SAME HOUDEHOLD, UNLIMITED SOCIAL ACTIVITIES, UP TO 4 SERVICES PER YEAR.: $25.00 per month for 12 months

1. FULL MEMBERSHIP, HOUSEHOLD, 495.00 FOR 12 MONTHS, TWO PEOPLE IN THE SAME HOUSEHOLD, UNLIMITED SOCIAL ACTIVITIES, UP TO 12 SERVICES PER MONTH.: $45.00 per month for 12 months

2. FULL MEMBERSHIP, INDIVIDUAL, 495.00 FOR 12 MONTHS, UNLIMITED SOCIAL ACTIVITIES, UP TO 12 SERVICES PER MONTH: $45.00 per month for 12 months

First emergency contact name

First emergency contact cell phone

First emergency contact phone

First emergency contact email

First emergency contact address

First emergency contact relationship

Current Health

Mobility issues

Home type

Employment status

How long have you lived in the city

Your interests what do you love doing

How did you hear about us

What interested becoming member

Additional Comments

I confirm that I have read, consent and agree to Revolutionaging’s (Helpful Village’s) TERMS OF USE and PRIVACY POLICY

Thank you for your interest

Thank you for your interest and we will be in touch with you very soon!