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2024 Member Interest Form
Please complete this form to learn more joining the Seacoast Village Project. One of our staff members will get back to you.
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* Indicates required question
I'm interested in becoming a:
*
Member
Member and Volunteer
First Name
*
Your answer
Last Name
*
Your answer
Type of membership
*
Individual
Household
Street Address
*
Your answer
City, State, zip
*
Your answer
Email Address
*
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Preferred Method of contact
*
Email
Phone
Mail
Preferred Phone
*
Home
Cell
How did you hear about us?
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Event/Presentation
From a Village Member or Volunteer
Member appeal
Seacoast Village website
Seacoast Village promotion (flyer, sign, etc.)
From a Health Care Professional
Other:
How do you prefer to discuss the next steps with a Seacoast Village representative?
*
By phone
In person at our Carey Cottage office in Portsmouth
Notes
Your answer
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