Lamorinda Village Membership Application Form

Lamorinda Village Membership Application
Thank you for your interest in Lamorinda Village! Lamorinda Village is a local nonprofit dedicated to helping older adults thrive at home with the support of a caring community. Through our volunteer services, healthy aging wellness programs, and meaningful connections, we empower our members to live independently and with peace of mind.
Membership Application Date

MonthDayYear
Date
Member Fees

$360 Individual$600 Household*
* 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

Please note, we do offer supported memberships for people who qualify. Please contact the office for more information. info@lamorindavillage.org 925 283-3500
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
What interests you in becoming a member of Lamorinda Village?
Thank you! Our Member Services Coordinator will be contacting you.
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