KFNV Membership Application Form
Welcome to King Farm Neighbors Village (KFNV) and thank you for becoming a member. Please complete this application, indicate if you are requesting services and acknowledge your becoming a member at the end of the forms. All applications will be reviewed and a telephone or an in-person interview will be scheduled for members seeking services.

The information we collect is for statistical and reporting purposes only and will be kept strictly confidential.
Email *
About You
Today's Date *
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Address *
Full Name *
Phone Number *
Please submit the best number to reach you at.
Emergency Contact Information
Emergency Contact Name *
Relationship *
Address
Phone Number *
Please list the best number to reach your emergency contact
Email *
Services
You can indicate here which services you are looking for, or you can apply for them at a later time on our website.
Indicate Which Services You Are Applying For *
Please check all that apply. For transportation services KFNV partners with Senior Rides.
Required
Demographics
Gender
Clear selection
Primary Language Spoken *
Racial and Ethnic Background
Clear selection
Current Living Arrangements *
Pets
Clear selection
Smoker
Clear selection
Annual Income Level
Clear selection
Mobility
Mobility Issues *
Check all that affect your mobility.
Required
Assistive Mobility Devices *
Please indicate all assistive mobility devices you use
Required
Donation to KFNV
King Farm Neighbors Village depends on charitable contributions from organizations and individuals to fund the programs and services it provides to the King Farm community.

At this time, we do not require annual membership dues; however, we do ask that you consider making a financial contribution to the organization if you are able to do so.

Donations are tax deductible and enable us to provide educational and social events as well as services to help community members “age in place.”

Donations can be submitted via check made out to King Farm Neighbors Village, or through our Paypal account: https://paypal.me/kfnvorg?locale.x=en_US.

Suggested contributions are:

Individual - $50
Household - S100
Members Code of Conduct
King Farm Neighbors Village, in partnership with Senior Rides, provides services for residents of the King Farm Community in Rockville, MD, and reserves the right to determine member eligibility. Members agree to be bound by the service descriptions provided by King Farm Neighbors Village and agree to the following guidelines of participation:

Member Code of Conduct – All members agree to:

• Submit online or call the volunteer coordinator for service requests. Do NOT contact the volunteer directly.
• Submit online or call the volunteer coordinator as soon as you know you need a service to get on the schedule.
• Abide by the program policies and restrictions.
• Notify the volunteer coordinator of any ride or service cancellations as soon as possible.
• Be prepared to depart at the requested pick-up time or prepared for the scheduled service time.
• Be courteous to your volunteer and follow their instructions at all times.
• Be ambulatory or able to self-transfer into and out of the vehicle.
• Pay for any parking, tolls, groceries, prescriptions or other items you acquire during service.
• Contact the volunteer coordinator immediately if there is a problem or concern with a volunteer service provider.
Member Agreement/Waiver of Liability
I hereby certify that all information I have supplied in this membership application is true, complete and accurate. I understand that by submitting this membership application, I authorize inquiries to be made concerning my suitability as a member, and that this application is not a guarantee that I will be accepted as a member of King Farm Neighbors Village and Senior Rides.

I hereby affirm that I meet all minimum requirements for the program(s) I am applying for and have supplied such additional information as required. I agree to comply with and be bound by the policies of the program. Furthermore, I agree that King Farm Neighbors Village and/or Senior Rides may, for publicity purpose use my image and/or any comment or quotation made by me.

I understand that King Farm Neighbors Village and/or Senior Rides may collect medical information from me that may include diagnosis, symptoms, treatments, doctor visits or other similar information. Any such information provided is strictly confidential and will not be disclosed or used for any purpose other than providing services as requested herein.

I understand and agree that for any service performed for me which includes any period that I am under general anesthesia (or similar), it will be my sole responsibility to have assistance available for me by a third party. Any responsibility of King Farm Neighbors Village and/or Senior rides, its staff and volunteers ends when the scheduled transportation appointment is concluded and I am delivered to my residence.

I hereby release, waive, indemnify and hold harmless King Farm Neighbors Village and/or Senior Rides, its Directors, Officers, employees and volunteers from any and all loss, damages or liability including personal injury or death arising from my voluntary participation in the program(s) to which I have applied. I further agree that this Membership Application and Waiver of Liability is intended to be as broad and inclusive as is permitted by the laws of the State of Maryland, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I have read and voluntarily sign the Membership Application and Waiver of Liability. I do so recognizing that I have been advised by King Farm Neighbors Village and Senior Rides that I have the right to consult with my own legal counsel concerning the Membership Application and Waiver of Liability for clarification of any of the terms contained herein. I further agree that no oral representations, statements or inducements, apart from the foregoing written agreement, have been made.
By clicking this box I agree to the stated Members Code of Conduct and Members Agreement/Waiver of Liability. *
Required
Please print your name as acknowledgement of the Members Code of Conduct and Members Agreement/Waiver of Liability *
Signature
KFNV staff will review your application, and if accepted they will ask that you sign in the box below, and present it to them at an upcoming event, mail it or scan it.
Today's Date *
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If you assisted an individual in the filling out of this form, please provide your name here.
A copy of your responses will be emailed to the address you provided.
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