Membership Information Request

Thank you for your interest in becoming a member of our Village!

We are a nonprofit dedicated to helping older adults thrive at home with the support of a caring community. Through volunteer services, healthy aging and wellness programs, and meaningful connections, we help our members remain independent, engaged, and connected to their community.

As part of this application, we ask a few optional questions that you are not required to answer. This information helps us better understand the community we serve and demonstrate our impact, including whom we are reaching and how we are supporting diversity, inclusion, and mobility. Your responses will not affect your eligibility for membership.

Your Information

First name

Last name

Phone

Cell phone

Date of birth

Marital status

Gender

Local village

Race

Address

Number

Street

City

State

Zip Code

Available Membership Options

CVV Household Monthly Payments: $660.00 for 12 months ($55.00/mo if paid monthly) CVV Household Yearly Payments: $660.00 for 12 months CVV Single Monthly Payments: $480.00 for 12 months ($40.00/mo if paid monthly) CVV Individual Yearly Payments: $480.00 for 12 months CVV Test: for 12 months ($1.00/mo if paid monthly)

Additional Information

First Emergency Contact

First emergency contact name

First emergency contact relationship

First emergency contact cell phone

First emergency contact phone

First emergency contact email

First emergency contact address

Your interests what do you love doing

Special expertise

How did you hear about us

What made you interested in becoming a 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 contacting us — it’s a pleasure to connect! Our team is committed to providing friendly, professional assistance, and we’ll be reviewing your message right away. You’ll hear back from us soon.