Primary Member Name *

First Name

Last Name

Spouse (Secondary Member Name)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

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Please check for consent: *

I give my consent for Village Friends, Inc. to use any photographs of me in its publications, website, or promotions, but not as a direct endorsement of any product or service.

The Village Friends, Inc. newsletter will be emailed unless you prefer to receive it in the mail bu checking this box.

Membership Criteria *

Residence in Corry Area School District.

55 years of age or older.

Responsible for, and capable of, making key decisions about one's own life.

Living in a residence that presents no known threats to health or safety.

Self-sufficient in meeting personal care needs, either through self-care or arrangements with personal care giver.

Willing to provide advance contact information of family, friend, or other, that Village Friends, Inc. is permitted to contact in case of emergency.

Understanding that social events require a member to be fully ambulatory.

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

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