Membership Information Request

We are excited to have you as a part of this amazing community!

YOU are an important part of our puzzle!

This is not a true "application" but an indication of strong interest in becoming a member of UA Village. Once you complete and submit this information, it will be sent to the UA Village staff. They will review it and set up a time to chat in further depth and detail. Our goal is to exceed expectations, so it is important that we are all on the same page as to what UA Village is and isn't!

First name

Last name

Phone

Cell phone

Date of birth

Marital status

Gender

Ethnicity

Number

Street

City

State

Zip Code

Available Membership Options

Household:$360.00 for 12 months ($30.00/mo if paid monthly)

Individual:$360.00 for 12 months ($30.00/mo if paid monthly)

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

Mobility issues

Special needs

Home type

Home ownership

Vocational/Professional Experience

How long have you lived in the city

Your interests what do you love doing

Special expertise

How did you hear about us

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!