Free to Live Membership Application

As a Free to Live Member, you become part of a community committed to your healing and growth. Members enjoy access to free and discounted services, priority notification and early registration for workshops and events, peer support circles, family-friendly programming, holiday and seasonal support, connections to trusted local resources, and members-only communications. When capacity allows, members may also access wellness partners, career and financial empowerment opportunities, and pathways to volunteer and lead. Above all, you'll have a community that sees you, celebrates your milestones, and walks alongside you on your journey.

Free to Live's Membership Perk for Survivors(young and old):

Parents' Night Out (June 19th, 2026) | Children 6 to 18 years old

Dick's House of Sports is partnering with Free to Live for kids to come and enjoy a 2 hour fun filled time while giving parents a break!

(A special link to follow after your application has been submitted.)

Cup of Courage(June 20th 2026)| Adults

Free to Live is partnering with Inclusion Coffee to bring a different way healing -over coffee. Sign up to have your cup filled with great techniques to move past trauma from Domestic Violence.

Full Legal Name

First NameMiddle NameLast Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Permission to leave voicemail or send a text to this number

Preferred Method of Contact

Other

City

State

Zip Code

Household Size

Eligibility & Consent

Other

Membership Option

Dependent Name (1)

First NameLast Name

Date of Birth

Date

Dependent Name (2)

First NameLast Name

Date of Birth

Date

Dependent Name (3)

First NameLast Name

Date of Birth

Date

Dependent Name (4)

First NameLast Name

Date of Birth

Date

Programs of Interest

How Did You Hear About Us?

Why Are You Interested in Membership?

Primary Goal for Membership

Preferred Start Date

Date

Communication Preferences

Additional Membership Notes

Please describe your current living situation

Do you currently have stable housing?

Are you currently receiving support services?

If yes, please describe the services you receive

How many people live in your household?

Which types of support would be most helpful to you?

Please share any additional information we should know about your situation

Do you have any accessibility needs?

If yes, please describe your accessibility needs

Is there anything else you would like to add to your application?

Acknowledgment

I agree to the membership terms and conditions

I acknowledge that I have read and understood all membership policies

I confirm that the information provided in this application is true and complete

I understand that membership approval is subject to review and eligibility requirements

Date

Free to Live Membership Application

Application / Contact / Eligibility

Membership Details

Additional Information

Final Agreements and Signature