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Membership Application
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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
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