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.

Nombre

Apellido

Teléfono

Móvil

Date of birth

Gender

Sexual orientation

Ethnicity

Número

Calle

Ciudad

Estado

Código postal

Opciones de Membresía Disponibles

Friendly Caller Membership: $0.00 para 12 meses

Social Monthly Membership: $12.00 para mes

Individual Monthly Membership: $20.00 para mes

Household Monthly Memberhip : $25.00 para mes

Social Membership: $144.00 para 12 meses

Individual Membership: $240.00 para 12 meses

Household Membership: $300.00 para 12 meses

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

Comentarios Adicionales

Confirmo que he leido, consiento y estoy de acuerdo con los términos de Revolutionaging’s (Helpful Village’s) CONDICIONES DE USO y POLÍTICA DE PRIVACIDAD

Gracias por su interés

Gracias por su interés, le contactáremos muy pronto!