Parkland Village Membership Registration form:
First name (legal): _____________________ Preferred name: ____________________
Last name: ______________________________________________________________
Year of birth: ______ or: under 50, 50-59, 60-64, 65-74, 75-85, 85+
Cell phone: (____) _______ Is your cell phone your preferred phone contact? Yes No Landline phone: (____) _______
Primary email address: ______________________________________________________
Secondary email address: ____________________________________________________
May we send you Parkland Village newsletters, and updates via email? Yes No
Conversational Spanish or fluent in Spanish? Yes No
Home address and zip code: ___________________________________________________________________________
Is this a registration for a Household membership? Y N
What is the first and last name of the second member?
___________________________________________________Preferred________________
Second member year of birth: ______ or: under 50, 50-59, 60-64, 65-74, 75-85, 85+
Third elderly or disabled member:_______________________________________________
Third member year of birth: ______ or: under 50, 50-59, 60-64, 65-74, 75-85, 85+
How did you hear about Parkland Village? _________________________________________
What compels you to become a Parkland Village member? Check all that apply.
____ I want to help build community and make new friends.
____ I want to participate in organizing Parkland Village. (e.g., a committee or project)
____ I want to volunteer to provide direct services.
____ I anticipate needing services within the next year.
____ I anticipate needing services very soon.
____ Other (please elaborate) _______________________________________________
Yearly membership dues are $150 for an individual and $200 for a household. If you cannot afford these dues, call 505-417-8799 or email [email protected] to learn about financial assistance. We accept cash, checks made out to Parkland Village, and credit/debit cards. To pay by credit card or with debit card, call 617-851-8151.
Please send checks and registration forms to: Treasurer, Parkland Village, Post office Box 8738, Albuquerque, NM 87198