Lamorinda Village Membership Application Form

Lamorinda Village Membership Application

After you complete this application, you will be contacted by the Village office.
Membership Application Date

MonthDayYear
Date
Member Fees

$360 Individual$600 Household*
Please note, we do offer supported memberships for people who qualify. Please contact the office for more information.

* If you and your partner/spouse live in the same household, then the household membership applies

Contact our office if you wish to arrange automatic monthly payments
Primary Member*

First NameLast Name
Birth date*

MonthDayYear
Date
Gender
Address*

Street Address

Apartment or Unit # (enter N/A if none)

CityState

Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email*
Spouse/Partner (if applicable)

First NameLast Name
Birthdate

MonthDayYear
Date
Gender
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
Other Contact Information (*items are required)
Emergency Contact #1**

First NameLast Name
Relationship*
Emergency Contact #1 Email**
example@example.com
Emergency Contact #1 Telephone:**

Area CodePhone Number
Emergency Contact #2

First NameLast Name
Relationship
Emergency Contact #2 Email
example@example.com
Emergency Contact #2 Telephone:*

Area CodePhone Number
Primary Care Physician Name
example@example.com
Primary Care Physician telephone:

Area CodePhone Number
Hospital Affiliation
Current Insurance Provider (Medicare, Health Net, etc.)*
How did you hear about Lamorinda Village?

FriendCommunity CenterNewsletterCommunity EventSWELLOther
Current Insurance Provider (Medicare, Health Net, etc.)
What interests you in becoming a member of Lamorinda Village?
____________________________________________________________________________________
Should be Empty: