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New Membership Application
First name
Last name
email
Phone
Cell phone
Date of birth
Gender
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Female
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Other
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Number
Street
City
State
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Alabama
Alaska
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Zip Code
Available Membership Options
Individual: $75.00 for 12 months
Household: $125.00 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
Current Health
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Excellent
Good
Chronic condition that interferes with my daily living activities
Prefer not to answer
Mobility issues
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No mobility issues
Walk with cane
Walk with walker
Use a wheelchair
Uses service animal
Need assistance getting in and out of cars
Difficulty with Stairs
Prefer not to answer
Special needs
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None
Vision impaired
Hearing impaired
Memory issues
Other
Your interests what do you love doing
Special expertise
How did you hear about us
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Email Solicitation
Friend or Acquaintance
Marketing Telephone Call
Meeting or Event
Newspaper or Magazine Article
Online Search (Google, Bing, etc.)
Other
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!