Membership Information Request

Completing this information request is the first step to find out if you want to become a member of Coastal Neighbors Network. After submitting this form, you will receive a call from our Executive Director, Andy Pollock. He will contact you to discuss scheduling an introduction meeting.

First name

Last name

Phone

Cell phone

Date of birth

Marital status

Gender

Number

Street

City

State

Zip Code

Available Membership Options

Service Member Individual - Short Term: $200.00 for 3 months

Service Member Household - Short Term: $250.00 for 3 months

Supporting Member - Annual: $350.00 for 12 months

Service Member Individual - Annual: $660.00 for 12 months

Service Member Household - Annual: $900.00 for 12 months

How did you hear about us

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!