Volunteer Registration Form

Welcome to MultiCare Yakima Memorial's Volunteer Program

Thank you for your time and contribution! As a volunteer in a health care setting, you must meet the same health requirements as employees. These requirements are for the safety of the patients we serve.

Health Requirements for Volunteers:
*Proof of vaccination or immunity by lab (titers) for: Measles, Mumps, Rubella
*Varicella (Chicken pox)
*Two Step Tuberculosis Skin Test
*Influenza Vaccine

All volunteers must be vaccinated annually in a timely manner and in accordance with the annual influenza policy. You may provide documentation if you receive your shot elsewhere.

To locate records check with: previous employers, parents/baby book, high school/college, physician, military, local/state health department. If you are unable to obtain these health records, Employee Health orders blood tests and provides vaccinations and/ or Tuberculosis testing, at no cost to you.)

Please make note of the e-mail address and password used, as you will need it for future system use.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Personal Information

* First name

Middle name

* Last name

* Address

* City

State (as combo)

* Zip/postal

* Home phone

* Mobile

Gender

* Date of birth

How did you hear about us?

* Area of Interest (ie: Administrative duties, North Star Lodge, Children's Village, Ohana, Snuggle Buddies and/or Hospital)

Emergency Contact Information

* Contact name

* Relationship

* Home phone

* Mobile

Reference 1

* Name

Relationship

* Phone

* E-mail

Reference 2

* Name

Relationship

* Phone

* E-mail

Disclosure Statement

Pursuant to the requirements of RCW 43.43.834, MultiCare Yakima Memorial must ask you to complete the following Applicant Disclosure Statement. This information will be kept confidential. Please answer fully and accurately.

Have you ever been convicted of any crimes?

If yes, please check that all apply

Have you ever been convicted of a crime related to the manufacture of, delivery of, or possession with intent to manufacture or deliver a controlled substance?

Have you ever been found by any agency, court or disciplinary board final decision to have committed any of the following acts against a child, a vulnerable adult or developmentally disabled person

If yes, please check all that apply

For all items where you have answered yes, specify the conviction, finding or action date(s), specify the sentence(s) or penalty(ies) imposed, prison release date(s) and current standing (e.g., parole, work release). For all Items with an asterisk (*) above, provide a description of the victim including the victim's age. Please use text box, if needed.

Have you ever been convicted of any other crime?

If yes, please identify the offense(s), provide the date(s) of the conviction(s), the name of the court, (e.g., Yakima county Superior Court) and the sentence imposed.

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Signature (electronic)