Please enable JavaScript in your browser to complete this form.Primary Member Name *Primary Member Date of Birth *Secondary Member Name (optional)Secondary Member Date of Birth (optional)Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell PhoneEmail *Communication Preference *PhoneEmailTextEmergency Contact InformationEmergency Contact Name *Relationship *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneEmail *Please check the services you are interested in receiving.Transportation (appointments., shopping, errands)Computer/technologyGrocery shopping or errands for youVisitingWalking/exercise partner Check-in callsOccasional Light yard workReadingMinor household repairs/maintenanceOccasional snow shovelingOccasional light housekeeping How did you hear about Yakima and Selah Neighbors’ Network?Do you have a pet? What kind and how many?Are you a smoker?YesNoAre 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. *YesNo 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!Submit