Online Application – Silver Spring Village

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MEMBERSHIP TYPE

Membership Type*

For household applications, please fill out a separate form for each individual.

CONTACT INFORMATION

Full Name*

First Middle Last Suffix

Preferred Name/Nickname*

Address*

Street Address Address Line 2 City State ZIP Code

Preferred Phone*

Preferred Phone Type*

Home

Mobile

Work

Alternate Phone

Alternate Phone Type

Home

Mobile

Work

Email*

CONTACT INFORMATION (SECOND MEMBER)

Full Name*

First Middle Last Suffix

Preferred Name/Nickname*

Address*

Street Address Address Line 2 City State ZIP Code

Preferred Phone*

Preferred Phone Type*

Home

Mobile

Work

Alternate Phone

Alternate Phone Type

Home

Mobile

Work

Email*

PROFESSIONAL INFORMATION

Current Work Status*

Career/Profession*

Hobbies, Interests & Special Kills

PROFESSIONAL INFORMATION (SECOND MEMBER)

Current Work Status*

Career/Profession*

Hobbies, Interests & Special Kills

TRANSPORTATION INFORMATION

Do you drive?*

Yes

TRANSPORTATION INFORMATION (SECOND MEMBER)

Do you drive?*

Yes

HOUSING INFORMATION

Housing Type*

Living Arrangements*

Other*

Provide the name of other(s) in your home and their relationship to you (e.g., “Barbara Smith, daughter”)*

Pets*

Yes

Indicate the number and type of pets (e.g., “2 cats, 1 bulldog”)*

Neighborhood or Homeowners' Association Name*

COMMUNICATIONS INFORMATION

Do you have internet access?*

Yes

Do you use social media?*

Check All That Apply

None

Facebook

Instagram

Neighborhood Listserve

X (formerly Twitter)

Other

Other*

Email is more environment-friendly, less costly, and faster than sending printed materials. May we email you Village communications?*

Yes

Maybe

VOLUNTEER INTEREST

Are you interested in learning about volunteer opportunities at the Village?*

Yes

Maybe

VOLUNTEER INTEREST (SECOND MEMBER)

Are you interested in learning about volunteer opportunities at the Village?*

Yes

Maybe

EMERGENCY CONTACT(S)

Please provide the names of at least two emergency contacts*

Click the blue + sign to add additional emergency contacts.

Name

Relationship to me

Home Phone

Mobile Phone

E-Mail

Street Address

City/State/Zip

Has a key to my home? (Yes/No)

I grant permission to the Executive Director, Director of Volunteer Services or their assigns to share information with the person(s) listed if they notice a marked decline in my health or living conditions.*

Yes

DEMOGRAPHIC INFORMATION

A response is required to each question. You may select "prefer not to answer," but we encourage responses to help us better understand how well our membership reflects the diversity of Silver Spring. Personal demographic information is confidential and is reported only in non-identifiable aggregate form.

Birthdate*

Gender*

Other*

Preferred Pronouns*

Other*

Ethnicity*

Race*

Other*

I identify as LGBTQ+*

Accommodation Needs

None

Cognitive Impairment

Hearing Impairment

Low Vision

Mobility

Other

Description of Other Accommodation Needs*

DEMOGRAPHIC INFORMATION (SECOND MEMBER)

Birthdate*

Gender*

Other*

Preferred Pronouns*

Other*

Ethnicity*

Race*

Other*

I identify as LGBTQ+*

Accommodation Needs

None

Cognitive Impairment

Hearing Impairment

Low Vision

Mobility

Other

Description of Other Accommodation Needs*

Household Income*

MEMBER DIRECTORY

Do you want your CONTACT information (i.e., name, address, phone and email) to be included in the Member Directory available only to other Village members?*

Yes

MEMBER DIRECTORY (SECOND MEMBER)

Do you want your CONTACT information (i.e., name, address, phone and email) to be included in the Member Directory available only to other Village members?*

Yes

REFERRAL INFORMATION

Were you referred to the Village by a current Village member?*

Yes

Name of the current Village member who referred you.*

MEMBERSHIP AGREEMENT

Membership Agreement*

OUR SERVICES
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.

VOLUNTEER SCREENING
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.

PHOTO/VIDEO RELEASE
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.

RIGHT TO DECLINE OR DISCONTINUE MEMBERSHIP
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.

LIABILITY
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.

Member 1 Name*

First Last

Date*

Member 1 Signature*

Member 2 Name*

First Last

Date*

Member 2 Signature*

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