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Artist Delma Tayer-YSNN Founding Member
HomeMember Application

This is a SAMPLE. Please print application from the tab below.

MEMBER APPLICATION

GENERAL MEMBER INFORMATION

 

Primary Member Name:

 

Date of Birth

 

Secondary Member Name:

 

Date of Birth

 

Address:

 

City

Zip

Home Phone:

 

Cell Phone:

Cell Ph.

Email:

 

Email:

 

Communication Preference: Phone Email Text

 

 

 

 

EMERGENCY CONTACT INFORMATION

Name:

 

Relationship

 

Address:

 

Phone #(s):

Email:

Name:

 

Relationship

 

Address:

Phone # (s):

Email:

 

 

Membership Fees

Individual $300/yr

 

Household (2) $400/yr

 

YSNN MEMBER BENEFITS

 

 

 

 

Services from our list

   

Invitations to social events

   

Invitations to educational events

   

Newsletter

 
   

Information on Interest Groups

   

Being a volunteer

   

We will be adding services as we grow.

 

 

SERVICES

Please check mark by services you are interested in receiving.

Transportation ( appts., shopping, errands)

 

Computer/technology

Grocery shopping or errands for you

 

Visiting

Walking/exercise partner

 

Check –in calls

Occasionl Light yard work

 

Reading

Minor household repairs/maintenance

 

Occasional Snow shoveling

Occasional light housekeeping

 

Other:

 

How did you hear about Yakima and Selah Neighbors’ Network?

 

Do you have a pet? What kind and how many?

 

Are you a smoker?

 

 

Are there any current health needs or chronic conditions that would be helpful for us to know? If yes, please describe.

 

 

 

 

I give permission for YSNN to use photos of me at YSNN events for promotional purposes. Yes_______ No ________

 

 

 

After your application is received, and interview or home visit will be scheduled during which we will discuss member services and benefits, review the member handbook and anwer any questions you might have. Confirmation of membership wil be made after the interview or home visit *NOTE we will take payment after this is complete. Thank you!

 

 

 

 

 

 

Signature: