Membership Information Request

After you submit this brief information application, we will review it and someone will be in touch within 7-10 days to obtain more information from you and schedule an interview in your home. You can also email us with additional questions at [email protected] or call and leave a message at 207-370-1896.

Your Information

First name

Last name

Phone

Cell phone

Date of birth

Address

Number

Street

City

State

Zip Code

Available Membership Options

Household: $375.00 for 12 months Individual: $300.00 for 12 months Individual with Scholarship: $150.00 for 12 months Household - monthly: $31.25 for 12 months Individual - monthly: $25.00 for 12 months Individual with Scholarship Monthly: $12.50 for 12 months

Additional Information

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.