Demo Village. A community of seniors supporting each other as they age in their own homes

1

Your Information

First name

Last name

email

Most Village correspondence is sent via email:

I use email (this is a good way to notify me) I do not use email (if you email me information, I will likely not see it)

Phone

Cell phone

I agree to receive SMS/text messages from Demo Village about events, volunteer opportunities and service updates

Message frequency varies. Message & data rates may apply. Reply STOP to unsubscribe. Reply HELP for help. Privacy Policy and Terms of Use

Date of birth

Marital status

Gender

Sexual orientation

Pronouns

Local village

Race

Ethnicity

2

Address

Number

Street

City

State

Zip Code

Available Membership Options

Individual DT: $1,200.00 for 12 months ($100.00/mo if paid monthly) Monthly UN: $1,000.00 for 12 months ($100.00/mo if paid monthly) MonthlyDT: $800.00 for 12 months ($95.57/mo if paid monthly) Social: $540.00 for 12 months Household Full: $515.30 for 12 months Membership type household 2: $500.00 for 12 months Membership type household 2 monthly: $480.00 for 12 months ($40.00/mo if paid monthly) Membership type household 2 monthly autoextend: $480.00 for 12 months ($40.00/mo if paid monthly) Household: $469.00 for 12 months ($39.00/mo if paid monthly) Household: $468.00 for 12 months ($39.00/mo if paid monthly) Household: $468.00 for 12 months ($39.00/mo if paid monthly) Membership type 1 monthly: $360.00 for 12 months ($30.00/mo if paid monthly) Membership type 1 monthly autoextend: $360.00 for 12 months ($30.00/mo if paid monthly) Membership type 1: $350.00 for 12 months Household - monthly: $300.00 for month Household: $300.00 for 12 months ($10.00/mo if paid monthly) Super VIP Pass: $250.00 for 12 months ($20.00/mo if paid monthly) Subsidized 25: $250.00 for 12 months ($10.00/mo if paid monthly) Individual: $200.00 for 12 months Individual - monthly: $200.00 for 12 months ($20.00/mo if paid monthly) test: $200.00 for 12 months Subsidized 50: $200.00 for 12 months ($9.00/mo if paid monthly) Test: $180.00 for 12 months ($10.00/mo if paid monthly) Household Instant: $175.00 for 12 months Instant Individual: $120.00 for 12 months ($10.00/mo if paid monthly) test 3: $120.00 for 12 months ($10.00/mo if paid monthly) Village Membership Dual: $100.00 for 12 months ($10.00/mo if paid monthly) one month: $60.00 for month A-Individual: $50.00 for 12 months Membership Light for Volunteers: $50.00 for 12 months Polina 2: $20.00 for 12 months ($50.00/mo if paid monthly) Polina: $10.00 for 12 months ($30.00/mo if paid monthly) A-Individual-free: $0.00 for 12 months Subsidized Membership: $0.00 for 12 months Membership type 3: $360.00 per month for 12 months Membership type 4 individual monthly: $66.00 per month for 12 months Membership type 4 ind monthly autoextend: $60.00 per month for 12 months membership type 3 household monthly autoextend: $50.00 per month for 12 months membership type 3 household monthly: $45.00 per month for 12 months membership 3 monthly autoextend ind: $40.00 per month for 12 months Sponsored : 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

Pet Information

First pet name

First pet species

First pet breed

First pet date of birth

Second pet name

Second pet species

Second pet breed

Second pet date of birth

Current Health

Mobility issues

Special needs

Home type

Home ownership

Employment status

Vocational/Professional Experience

How long have you lived in the district

How long have you lived in the city

Your interests what do you love doing

Special expertise

How did you hear about us

What made you interested in becoming a member?

Do you hold an OLLI Membership?

Additional Comments

I confirm that I have read, consent and agree to Revolutionaging’s (Helpful Village’s) TERMS OF USE and PRIVACY POLICY

Membership Application Form