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.

First name

Last name

Phone

Cell phone

Date of birth

Gender

Sexual orientation

Ethnicity

Number

Street

City

State

Zip Code

Available Membership Options

Friendly Caller Membership: $0.00 for 12 months

Social Monthly Membership: $12.00 for month

Individual Monthly Membership: $20.00 for month

Household Monthly Memberhip : $25.00 for month

Social Membership: $144.00 for 12 months

Individual Membership: $240.00 for 12 months

Household Membership: $300.00 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

Second emergency contact name

Second emergency contact cell phone

Second emergency contact phone

Second emergency contact email

Second emergency contact address

Second emergency contact relationship

Mobility issues

Special needs

Home type

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!