Stay at Home in Wilton Membership

Stay at Home in Wilton Membership
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Cell/Mobile

Area CodePhone Number
Fax

Area CodePhone Number
Preferred Method of Contact
Emergency Contact #1
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2 (someone outside your home, i.e. friend or neighbor):
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Special circumstances or home issues you would like us to note:
Members' Children
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Known health issues:
Primary doctor
Birthday

MonthDayYear
Date
Wilton affiliations (Club, Church, Synagogue, etc.)
Member Who Suggested You Join Us
Would You Also Like to Volunteer?

YesNo
Area of Interest:
Services that will be accessible include Household Services, Transportation, and Social Programs.

These services are to be provided on a volunteer basis, and best efforts will be made to assure that these services are provided in a timely, safe and proper manner, recognizing that an occasional mistake will be made for which Stay at Home in Wilton is not liable. Recommended contractor services are solely provided by the contractor, and our participation is only to assure that the contractors are properly licensed and insured.

Member acknowledges and agrees that Stay at Home in Wilton is not responsible for any damages or liabilities that result from Member’s use of Stay at Home In Wilton’s services.
Signed by Member

Clear
Date

MonthDayYear
Date
I am:

An existing member updating my informationApplying for membership with this form
Please note: all fields marked with asterisks are required for the form.
For new members, please send completed form with a check to Stay at Home in Wilton, or visit www.stayathomeinwilton.org/paydues to pay by debit or credit card online.
Should be Empty:

Stay at Home in Wilton Membership

Members' Children