Membership Application

Thank you for filling out an application with The Villages at Mary's House. We are excited to have you and look forward to being a part of your story. Once your application is submitted, you will receive a call from a village member.

The Villages at Mary's House may send general emails about village participation and business, such as newsletters, event notices, essential updates, and similar announcements. Our system will securely hold the information provided, but we will not sell any of your data.

Potential members facing economic hardship will not be turned away from membership and will be offered membership on a pay-what-you-can agreement.

Your Information

First name

Last name

Phone

Cell phone

Date of birth

Gender

Sexual orientation

Ethnicity

Address

Number

Street

City

State

Zip Code

Available Membership Options

Household Membership: $300.00 for 12 months Individual Membership: $240.00 for 12 months Social Membership: $144.00 for 12 months Household Monthly Memberhip : $25.00 for month Individual Monthly Membership: $20.00 for month Social Monthly Membership: $12.00 for month Friendly Caller Membership: $0.00 for 12 months

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

Second Emergency Contact

Second emergency contact name

Second emergency contact relationship

Second emergency contact cell phone

Second emergency contact phone

Second emergency contact email

Second emergency contact address

Mobility issues

Special needs

Home type

Your interests what do you love doing

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.