Member Application - Yakima & Selah Neighbors' Network

Primary Member Name *

Primary Member Date of Birth *

Secondary Member Name (optional)

Secondary Member Date of Birth (optional)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email *

Communication Preference *

Emergency Contact Information

Emergency Contact Name *

Relationship *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Please check the services you are interested in receiving.

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

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

Are you a smoker?

Yes
No

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, an interview or home visit will be scheduled during which we will discuss member services and benefits, review the member handbook and answer any questions you might have. Confirmation of membership will be made after the interview or home visit.

*NOTE we will take payment after this is complete.

Thank you!

Membership Application

Emergency Contact Information