Check and Connect Volunteer Application - Aging & Long Term Care of Eastern Washington

Name: *

First Last

Email: *

Phone: *

Address: *

Street Address Address Line 2 City State ZIP Code

Date of Birth: *

Sex:

Female
Male
Decline

Tell us a little about why you’d like to volunteer with this program:

How did you hear about us? *

Event
Community Presentation
Referral
Social Media
Website
Newspaper
Radio
Television
Other

How did you hear about us - Other *

For the safety of our clients, Aging and Long Term Care of Eastern Washington conducts a Washington State Request for Criminal History Information on all volunteers having contact with our clients. By checking the box, I authorize Aging and Long Term Care of Eastern Washington to conduct background checks. *

I Consent
I Refuse Consent

E-Signature: *

DSHS Nondisclosure Agreement *

I hereby confirm that I have read the DSHS Nondisclosure Agreement and agree to its terms.

I agree