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First name
Last name
email
Phone
Cell phone
Allow text messages from Demo Village?
Date of birth
Marital status
Please choose...
Divorced
Married
Single
Widowed
Other
Prefer not to answer
Gender
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Female
Male
Other
Prefer not to answer
Sexual orientation
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Straight/Heterosexual
Bisexual
Gay /Lesbian/Same-Gender Loving
Questioning /Unsure
Declined to Answer
Not Asked
Not listed. Please specify...
Ethnicity
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African American
Asian
Hispanic
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Other
Prefer not to answer
Number
Street
City
State
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Alabama
Alaska
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Arkansas
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Zip Code
Available Membership Options
membership 3 monthly autoextend ind: $40.00 per month for 12 months
membership type 3 household monthly: $45.00 per month for 12 months
membership type 3 household monthly autoextend: $50.00 per month for 12 months
Membership type 4 ind monthly autoextend: $60.00 per month for 12 months
Membership type 4 individual monthly: $66.00 per month for 12 months
Membership type 3: $360.00 per month for 12 months
Subsidized Membership: $0.00 for 12 months
Membership Light for Volunteers: $50.00 for 12 months
one month: $60.00 for month
Village Membership Dual:$100.00 for 12 months ($10.00/mo if paid monthly)
Test 2:$120.00 for 12 months ($10.00/mo if paid monthly)
test 3:$120.00 for 12 months ($10.00/mo if paid monthly)
Instant Individual:$120.00 for 12 months ($10.00/mo if paid monthly)
Household Instant: $175.00 for 12 months
test: $200.00 for 12 months
Individual - monthly:$200.00 for 12 months ($20.00/mo if paid monthly)
Working Household -- Monthly:$200.00 for 12 months ($20.00/mo if paid monthly)
Individual: $200.00 for 12 months
Super VIP Pass:$250.00 for 12 months ($20.00/mo if paid monthly)
Household - monthly: $300.00 for month
Membership type 1: $350.00 for 12 months
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)
Household:$468.00 for 12 months ($39.00/mo if paid monthly)
Household:$468.00 for 12 months ($39.00/mo if paid monthly)
Household:$469.00 for 12 months ($39.00/mo if paid monthly)
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)
Membership type household 2: $500.00 for 12 months
Household Full: $515.30 for 12 months
Social: $540.00 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
First pet species
First pet breed
First pet name
First pet date of birth
Second pet species
Second pet breed
Second pet name
Second pet date of birth
Current Health
Please choose...
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
Please choose...
None
Vision impaired
Hearing impaired
Memory issues
Other
Home type
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Single Family
Condo or Apartment
Multi Story with Stairs
Multi Story with Elevator
Other
Home ownership
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Renter
Owner
Employment status
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Full Time
Part Time
Self-Employed
Unemployed
Retired
Occupation
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
Please choose...
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
Do you hold an OLLI Membership?
Yes
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!