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 (509) 853-1917
Photo by Chrissy Schott
HomeMember Application


MEMBER APPLICATION

GENERAL MEMBER INFORMATION

 

Name:

 

Date of Birth

 

Name:

 

Date of Birth

 

Address:

 

City

Zip

Home Phone:

 

Cell Phone:

 

Email:

 

 

 

Communication Preference: Phone

 

Email

Text

 

EMERGENCY CONTACT INFORMATION

Name:

 

Relationship

 

Address:

 

Phone No(s):

Email:

Name:

 

Relationship

 

Address:

Phone No(s):

Email:

 

 

Membership Fees: Individual $300/yr Household (2) $400/yr

Payable by cash or check

YSNN MEMBER BENEFITS

 

Services from our list

Invitations to social events

Invitations to educational events

Website articles and information

Preferred contractor list

Being a volunteer

We will be adding services as we grow.

 

 

 

SERVICES

 

 

Put check mark by services you are interested in receiving: If you do not yet need these services, would you be willing to volunteer to offer these services: Put a “V” by services for which you are willing to volunteer.

 

Transportation (appts., shopping, errands)

 

Computer/technology

 

Grocery shopping or errands for you

 

Visiting/check-in calls

 

Referrals to local providers

 

Reading

 

Light yard work

 

Snow shoveling

 

Minor household repairs/maintenance

 

Walking/exercise partner

 

Emergency pet care

 

Light housekeeping

 

 

 

 

 

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

 

 

Do you have a pet?

 

What kind?

 

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 hereby apply for membership and give permission for YSNN to use photos of me at YSNN events for promotional purposes.

 

Signature:

 





For more information contact YSNN:

Phone: 509-853-1917

Email: ysnn.wa@gmail.com

Mail:  PO Box 11691, Yakima WA 98909