Membership Information Request

Completing this information request is the first step in applying to become a member of Coastal Neighbors. After submitting this form, you will receive a call from our executive director, Jackie Northrup. She will contact you to discuss scheduling an introduction meeting.

Coastal Neighbors Data Security Policy

Your Information

First name

Last name

Phone

Cell phone

Date of birth

Marital status

Gender

Address

Number

Street

City

State

Zip Code

Available Membership Options

Service Member Household - Annual: $900.00 for 12 months Service Member Individual - Annual: $660.00 for 12 months Supporting Member - Annual: $350.00 for 12 months Service Member Household - Short Term: $250.00 for 3 months Service Member Individual - Short Term: $200.00 for 3 months

Additional Information

Mobility issues

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 contacting us — it’s a pleasure to connect! Our team is committed to providing friendly, professional assistance, and we’ll be reviewing your message right away. You’ll hear back from us soon.