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Virginia Mason Memorial Volunteer Application
Volunteer Services - 2811 Tieton Drive - Yakima, WA 98902 - 575-8053

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. If you have immunization records, TB skin tests, CXR report, or lab results for the following tests, please bring them to your appointment with Employee Health.

Health Requirements for Volunteers:
*Proof of vaccination or immunity by lab (titers) for: Measles, Mumps, Rubella
*Varicella (Chicken pox)
*Two Step Tuberculosis Skin Test
Please bring any of the following Tuberculosis records: any previous TB Skin Tests (TST), chest x-ray or TB lab tests
*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.)
Home address
Emergency Contact Information
References (Need to exclude relatives)
Believing that Virginia Mason Memorial has need of my services as a volunteer, I agree to the following:

I will hold as absolutely confidential all information, which I may obtain directly or indirectly concerning patients, doctors, or personnel and I will not seek confidential information in regard to a patient.

I understand my services are donated to Virginia Mason Memorial without contemplation of compensation or future employment and are given with humanitarian or charitable reasons.

I am informed of the required minimum time commitment of 6 months or 100 hours. I understand what is expected and I am committed to fulfilling this requirement.
have the same effect as a written signature)
Disclosure Statement

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

Note: Virginia Mason Memorial will confirm your answers to these questions by:

1. Running a Washington State Patrol and/or national background check for criminal convictions.
2. Searching the Washington Courts database for civil adjudications as listed below; and,
3. For licensed personnel, checking the Department of Health credentials database for disciplinary actions.
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?
Financial exploitation?
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.

We may request your fingerprints, and will obtain, upon and during employment from the State Patrol criminal identification system a report of your record of criminal convictions as well as Office OF Inspector General reports. If you are hired before that report is available. YOUR VOLUNTEER SERVICE WILL BE CONDITIONED UPON THE RECEIPT OF A SATISFACTORY REPORT. We will make a copy of this report available to you upon your request.

UNDER PENALTY OF PERJURY, I certify the above information is true, correct and complete. I understand that if I become a volunteer I can be discharged for any misrepresentation of omission in the above statement. I also understand that if I become a volunteer, my volunteer service is conditioned on your receipt of a satisfactory report from the State Patrol and/or national background check.

I have read and understand the above information, and assert that all information provided by me is true and accurate.

My typed name below shall have the same force and effect as my written signature.
Please download our Volunteer Orientation ***IMPORTANT--- This file will be used to complete your orientation quiz***
When you submit your application, please wait to be directed to complete the orientation quiz!