Membership Application

Please complete the information below. If you have any questions or concerns, please call 920-333-1083.

Your Information

First name

Last name

Phone

Cell phone

Date of birth

Gender

Address

Number

Street

City

State

Zip Code

Available Membership Options

Household: $165.00 for 12 months Individual: $125.00 for 12 months Social: 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

Current Health

Mobility issues

Special needs

How did you hear about us

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 contacting us — it’s a pleasure to connect! Our team is committed to providing friendly, professional assistance, and we’ll be reviewing your message right away. You’ll hear back from us soon.