Membership Information Request

We anticipating launching UA Village Fall 2022! We are excited to have you as a part of this amazing community!

YOU are an important part of our puzzle!

This is not a true "application" but an indication of strong interest in becoming a member of UA Village. Once you complete and submit this information, it will be sent to the UA Village staff. They will review it and set up a time to chat in further depth and detail. Our goal is to exceed expectations, so it is important that we are all on the same page as to what UA Village is and isn't!

Nombre

Apellido

Teléfono

Móvil

Date of birth

Marital status

Gender

Ethnicity

Número

Calle

Ciudad

Estado

Código postal

Opciones de Membresía Disponibles

Household: $30.00 per month para 12 meses

Individual: $30.00 per month para 12 meses

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

Mobility issues

Special needs

Home type

Home ownership

Occupation

Your interests what do you love doing

Special expertise

How did you hear about us

Comentarios Adicionales

Confirmo que he leido, consiento y estoy de acuerdo con los términos de Revolutionaging’s (Helpful Village’s) CONDICIONES DE USO y POLÍTICA DE PRIVACIDAD

Gracias por su interés

Gracias por su interés, le contactáremos muy pronto!