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 info@parklandvillageabq.org

 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 to: Candy Nartonis, Treasurer, Parkland Village, Post office Box 8738, Albuquerque, NM 87198