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 info@independentseniorsnetwork.org or call and leave a message at 207-370-1896.

First name

Last name

Phone

Cell phone

Date of birth

Number

Street

City

State

Zip Code

Available Membership Options

Individual with Scholarship Monthly: $11.50 for 12 months

Individual - monthly: $23.00 for 12 months

Household - monthly: $30.00 for 12 months

Individual with Scholarship: $137.50 for 12 months

Individual: $275.00 for 12 months

Household: $350.00 for 12 months

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 your interest and we will be in touch with you very soon!