Village Neighbors Membership Application

We offer the kinds of help a neighbor might offer - to members who live on Chincoteague and who are at least 60 years old. These services are provided by volunteers who have been interviewed and oriented, and who have undergone a background check. They are a great group, and you’ll enjoy getting to know them!

Review our Membership Benefits page by clicking here. Download a Membership Handbook by clicking here.

First name

Last name

Phone

Cell phone

Date of birth

Marital status

Number

Street

City

State

Zip Code

Available Membership Options

Individual - monthly: $20.00 per month for 12 months

Household - monthly: $20.00 per month for 12 months

Individual: $240.00 for 12 months

Household: $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

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!