Village Neighbors Membership Application

Thank you for your interest in becoming a member of Village Neighbors. Our goal is to help connect, inspire and support the 60+ generation in our community in living active and exciting lives! If you are the 60+ generation, live on Chincoteague and meet basic ADL (Activities of Daily Living) requirements, please review the Village Neighbors Member Benefits and Member Handbook.

Basic ADL (Activities of Daily Living)

Ambulating: The extent of an individual’s ability to move from one position to another and walk independently.
Feeding: The ability of a person to feed oneself.
Dressing: The ability to select appropriate clothes and to put the clothes on.
Personal hygiene: The ability to bathe and groom oneself and maintain dental hygiene, nail, and hair care.
Continence: The ability to control bladder and bowel function
Toileting: The ability to get to and from the toilet, using it appropriately, and cleaning oneself
Do you manage your own medication regimen?

(ADL categories provided by the National Institute of Health)

Annual membership is $240 per person or couple for up to 10 services requests per month. We also offer short-term memberships of either three or six consecutive months for $120.00/$180.00 respectively. Fees can be paid in full by personal check, or monthly by credit card or electronic transfer. Refunds will be considered on an individual basis.

Village Neighbors is fiscally sponsored by the Island Community House, a 501(c)3 non profit organization founded in 2019. Our membership fee helps to absorb costs involved in running and sustaining this program. No one will be turned away for inability to pay the fee. Please contact us for more information.

First name

Last name

Phone

Cell phone

Date of birth

Marital status

Number

Street

City

State

Zip Code

Available Membership Options

12 Month Membership - Monthly Recurring Payment: for 12 months ($20.00/mo if paid monthly)

3 Consecutive Month Membership : $120.00 for 3 months

6 Consecutive Month Membership: $180.00 for 6 months

12 Month Membership - One Time Payment: $240.00 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

Mobility issues

Special needs

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!