Membership Application Request

Welcome to Potomac Community Village

We are very happy to learn that you are interested in joining our Village!

Please review the information in our Membership agreement and then fill in the information below.

A member of our membership team will contact you soon!

First name

Last name

Phone

Cell phone

Marital status

Gender

Ethnicity

Number

Street

City

State

Zip Code

Available Membership Options

Associate Individual (outside zip 20854): $50.00 for 12 months

Associate Household (outside zip 20854): $75.00 for 12 months

Individual (within zip 20854): $100.00 for 12 months

Household (within zip 20854): $150.00 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

First pet species

First pet breed

First pet name

First pet date of birth

Current Health

Mobility issues

Special needs

Home type

Home ownership

Employment status

Occupation

Your interests what do you love doing

Special expertise

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!