Membership Application Website 1 2 3 4 Progress saved Contact & Demographics Membership Type Select your membership type. * Learn more about the options. Regular Membership Plus Urgent Subsidized Contact Information First Name * Last Name * Date of Birth Address ZIP Code * Home Phone Preferred Cell Phone Preferred At least one phone number is required. Email * Do you regularly check email? Yes No N/A How would you like to receive Newsletter/weekly emails? Email Paper Both About You & Interests Basic Information Gender Identity Female Male Prefer to Self-Identify Prefer not to answer Please specify Do you identify as a member of the LGBTQ community? Yes No Prefer not to answer Pronouns What is your race/ethnicity? African American/Black Asian Hispanic/Latino/a Euro-American/White Native American/Pacific Islander Other Prefer not to specify If Other, please specify Marital Status Single Married/Partnered Divorced Widowed Other Prefer not to answer Home Style Apartment/Condo Single Family Years on Capitol Hill Skills & Interests Tell us a little more about your skills and interests What are your primary interests in joining the Village? Make new connections/friends Preparing for retirement Attend social, wellness, and educational events Volunteer opportunities Network of volunteer helpers Case management & referral services Interested in supporting CHV financially Health & Special Needs Special Needs / Health Information Special Needs Wheelchair Mobility Device Hearing Impaired Low Vision Service Animals Problems with Stairs Use Companion Support Home Accessibility Challenges Stairs Bathroom Other If Other, please describe Do you Drive? Yes No Primary Care Doctor Insurance Hospital in Case of Emergency Health Care Directives Yes No Advanced Power of Attorney Yes No Name Name Emergency Contact Emergency Contact Information First Name * Last Name * Relationship * Email Address City/State ZIP Phone * Do they have a key to the house? Yes No Back Next Submit Application
