Member Information
Primary Member
Name
Gender
Date of Birth
____ / ____ / _______
Contact Information
Home Phone
Cell Phone
Email Address
Home Address
Street Address
City
State
ZIP Code
Emergency Contact
Name
Home Phone
Cell Phone
Email Address
Additional Household Member (Optional)
Member #2
Name
Gender
Date of Birth
____ / ____ / _______
Contact Information
Home Phone
Cell Phone
Email Address
Address
Street Address
City
State
ZIP Code
Membership Options
We are pleased to offer lower membership rates to make our services more accessible. Members who are able to contribute at the Legacy Rate help support the continued growth of Gramatan Village and our programs.
Family Memberships
Full Membership
$400 per year
$35 per month*
Legacy Full Membership
$530 per year
$46 per month*
Associate Membership
$200 per year
$18 per month*
Legacy Associate Membership
$265 per year
$23 per month*
Individual Memberships
Full Membership
$300 per year
$26 per month*
Legacy Full Membership
$400 per year
$35 per month*
Associate Membership
$150 per year
$13 per month*
Legacy Associate Membership
$200 per year
$17.50 per month*
* Monthly memberships require a 12-month commitment with recurring monthly billing.
Payment Information
Payment Method
☐ Check Enclosed
☐ Credit Card
Credit Card Information
Amount to Charge
$_____________________
Card Type
☐ Visa
☐ Mastercard
☐ American Express
Card Number
Expiration Date
Security Code (CVC)
Name on Card
Signature
Return Completed Applications To
Gramatan Village
85 Pondfield Road
Bronxville, NY 10708
Membership Agreement
Gramatan Village (“GV”) is a nonprofit organization dedicated to helping older adults live comfortably, independently, and confidently in their own homes and communities.
Membership provides access to programs, activities, referrals, and services offered through trusted third-party providers.
Important Information
Membership lasts for 12 months from the date payment begins.
Members who pay monthly are enrolled in a recurring 12-month payment plan.
Third-party providers bill members directly for services they use.
GV carefully identifies trusted providers, but cannot assume liability for services provided by outside organizations or individuals.
Member Authorization
By signing below, I authorize Gramatan Village to:
Contact emergency contacts when health or safety concerns arise
Receive non-medical service information from providers to help monitor member satisfaction and support needs
Signatures
Member Signature
Date
____ / ____ / _______
Member #2 Signature (if applicable)
Date
____ / ____ / _______
