Free to Live Membership Application

Free to Live Membership Application

Complete this membership application using the original form fields and consent/signature areas. Please answer all required items and provide accurate contact information.
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.
Application / Contact / Eligibility
Full Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
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 Details
Membership Option

Other
Dependent Name(1)

First NameLast Name
Date of Birth

MonthDayYear
Date
Dependent Name(2)

First NameLast Name
Date of Birth

MonthDayYear
Date
Dependent Name(3)

First NameLast Name
Date of Birth

MonthDayYear
Date
Dependent Name(4)

First NameLast Name
Date of Birth

MonthDayYear
Date
Preferred Membership Term
Programs of Interest

Other
How Did You Hear About Us?
Why Are You Interested in Membership?
Primary Goal for Membership
Number of People Included in This Membership
Preferred Start Date
Communication Preferences

Other
Additional Membership Notes
Additional Information
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?

Other
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?
Final Agreements and Signature
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
Signature
Date

MonthDayYear
Date
Acknowledgment
Date of Birth

MonthDayYear
Date
Should be Empty:

Free to Live Membership Application

Application / Contact / Eligibility

Membership Details

Additional Information

Final Agreements and Signature