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New User Details
Yakima Valley Memorial Volunteer Application
Volunteer Services - 2811 Tieton Drive - Yakima, WA 98902 - (509)574-6729
Welcome to 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

*COVID Vaccine *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. (Hint: 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.)


Emergency Contact Information
References
Disclosure Statement

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

1. Crimes Against Persons and Crimes Relating to Financial Exploitation:
Have you ever been convicted of any of the crimes listed below?
If Yes, check all that apply and describe at number 4 below.
*See {part 4 below)
2. Drug-Related Crimes
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?
3. 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:
Domestic Violence?
Sexually assault or abuse?
Exploitation?
Financial exploitation?
Abuse?
4. For all items where you have answered yes in 1-3 above, 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.
5. 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.



 

I grant permission to Yakima Valley Memorial Hospital Association to verify and obtain information needed to process my volunteer application.  I hereby release all agencies contacted from any and all liability of damages for providing the information requested. Further, I certify that the above information is true and correct to the best of my knowledge.  I understand that misrepresentation or omission of facts is cause for rejection or termination of placement. Placement is contingent upon a satisfactory Criminal History Report. I understand that this application does not create a contract of employment or promise of future employment. I understand that my request to volunteer is voluntary, unpaid, and can be terminated at any time at the option of either the agency or myself.  I understand that my ID badge is my responsibility.  I will not loan it to anyone, will report immediately if lost or stolen, and will return it when I am no longer a volunteer for YVM.

 

My typed name below verifies that I have read and agree to comply with the above Confidentiality, HIPAA, and Acceptable Use Policies. I understand my responsibility in protecting these rights. My typed name below shall have the same force and effect as my written signature.

 

Signature: *