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Membership Type
Membership Type
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For household applications, please fill out a separate form for each individual.
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Associate Individual
Associate Household
Full Individual
Full Household
Trial Associate Individual
Trial Associate Household
Trial Full Individual
Trial Full Household
Applicant Information
Full Name
*
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Address
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Alternate Phone
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Email
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Gender
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Prefer not to answer
Other
Other
*
Preferred Pronouns
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He/Him
She/Her
They/Them
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Other
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Birthdate
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MM slash DD slash YYYY
Ethnicity
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Race
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Other
Other
*
I identify as LGBTQ+
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Yes
No
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Special Needs
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None
Hearing Impairment
Low Vision
Mobility
Other
Description of Other Special Needs
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Current Work Status
*
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Full-Time
Part-Time
Retired
Career/Profession
Hobbies, Interest & Special Skills
Do you drive?
*
Yes
No
Housing Information
Housing Type
*
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Apartment
Condo
Single-Family Home
Townhouse
Living Arrangements
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Alone
Spouse/Partner
Other
Other
*
If you live with others in your home, please provide their names and the nature of your relationship (e.g., “Barbara Smith, daughter”)
Pets
Cat(s)
Dog(s)
Other
If you have pets in your home, please indicate the number and specific type (e.g., “2 cats, 1 Doberman pinscher”)
Communications
Do you have access to internet?
*
Yes
No
Do you use social media?
*
Check All That Apply
None
Facebook
Instagram
LinkedIn
Twitter
Nextdoor
Neighborhood Listserve
Other
Other
*
Email is friendlier for the environment, less costly, and faster than sending printed copies. May we email you Village communications?
*
Yes
No
Volunteer Interest
Are you interested in learning about volunteer opportunities at the Village?
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Yes
No
Maybe
Emergency Contacts
Please provide the names of at least two emergency contacts
*
Click the blue + sign to add additional emergency contacts.
Name
Relationship
Home Phone
Mobile Phone
E-Mail
Street Address
City/State/Zip
Has key to my home? (Y/N or Yes/No)
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Remove
I grant permission to the Executive Director, Director of Volunteer Services or their assigns to share information with the person(s) listed in the event they notice a marked decline in my health or living conditions.
*
Yes
No
Member Directory
Do you want your CONTACT information to be included in the Member Directory?
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Yes
No
Washington Consumers' Checkbook Subscription
Members are eligible to receive an online subscription to Washington Consumers’ CHECKBOOK, a resource to locate reliable and affordable repair services, personal services, and more.
Do you wish to subscribe?
*
Yes, please share my information Washington Consumers’ CHECKBOOK
No, I do not want my information shared with Washington Consumers’ CHECKBOOK
Email to use (one per household)
Referral
If you were referred for membership by a current Village member, please provide their name.
MEMBERSHIP AGREEMENT
Membership Agreement
*
Silver Spring Village (the “Village”) is a 501(c)(3) nonprofit Maryland corporation organized to sustain a robust network of neighborhoods-helping-neighbors that supports older adults who wish to live as independently as possible and be fully engaged in their community as they age. The Village accomplishes its mission by offering an array of social, educational, recreational, and cultural activities and third-party vendor recommendations for all members; and volunteer-provided direct services for Full Members only.
Services volunteers are vetted and trained and undergo periodic criminal background and driving history checks. The Village does not guarantee the availability of a volunteer service at any given time, especially those requested with less than one week’s notice. Volunteers do not provide personal care services or home services that typically require a licensed professional.
The Village does not employ drivers, healthcare professionals, home services professionals, or any other service provider. The Village or its members may recommend professional service providers upon request. All ensuing contractual obligations are between the contracting member and the professional service provider. The Village does not warranty the quality of any professional service provider and assumes no liability or other responsibility arising from members’ use such services.
The Village may use my likeness, including but not limited to photographs and video and audio recordings, in both print and electronic form for promotional and educational purposes. Village events occurring in public spaces carry no expectation of privacy.
The Village retains the right to deny or discontinue membership for an individual whose needs or expectations it is unable to meet. Membership fees are non-refundable except in instances when the Village opts to discontinue membership. In the event an applicant for Full Membership declines a home visit or if the visit reveals circumstances that may make it unsafe for volunteers to provide certain services, the applicant will be required to sign an addendum to this agreement stipulating any services limitations.
In exchange for an applicant’s acceptance as a member by the Village, the applicant agrees to indemnify and hold harmless the Village against any and all loss, expense, and liability arising from or in any manner related to the Village’s performance and that of its agents and the activities or any volunteer or professional service provider used or recommended by the Village or its members.
I have read and understand the above terms and conditions of membership and agree that I and my heirs, successors, agents, and legal representatives are bound by said terms and conditions. These terms will remain in force subsequent to any and all future membership renewals.
Name
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Last
Member 1 Signature
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Email
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