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Non-Employee Worker, Student or Volunteer Placement Request
To submit your application, please complete these steps. Fields marked with a red asterisk (*) are required.

Email Registration

Your email address will be used as your login name allowing you to return to our website to update your profile.

If you are a returning applicant, please sign in or reset your password using the Login button.

Save Time

Use your resume or LinkedIn Profile to fill in many of the fields on this application form.

Personal Information

Additional Information

Please list the type of training program you are in (e.g. family medicine residency, medical assistant training program, nursing program, etc.).

Are you fluent in a language besides English? If so, please specify that language here.

Have you been convicted of a misdemeanor or felony? A conviction does not automatically bar you from a student rotation or volunteer opportunity. 

If you have a conviction on your record, please tell us about it here. Include the date of conviction, your age at the time of conviction, and the circumstances that lead to the conviction. If you run out of space, please email your response to students@yvfwc.org.

Attach your resume and upload all documents/files relevant to your placement request.

Upload Your Resume

Upload your resume if you have not already done so.

Note: You can attach a total of up to 10MB of data. Your resume and all attachments combined must be less than 10MB.

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Cover Letter and Resume Text

You can copy and paste your resume or cover letter into the box below.

  1. Please describe the type of placement (i.e., job shadow, internship, externship, etc.) you are looking for
  2. Include the location(s) in which you would like to be placed.
  3. If you have already secured a preceptor, please include that person's name here.
  4. Additionally, tell us why you are interested in Yakima Valley Farm Workers Clinic as a rotation/placement site. 

Attachments

Upload the following:

• TB test within the last year
• MMR
• Varicella
• Tdap booster (must be administered in the last 10 years)
• Hepatitis B (only if you are requesting a clinical experience)
• Flu vaccine (only during flu season)
• CPR or other basic life support certification (only if you are requesting a clinical experience)
• Blood Borne Pathogens training certificate (only if you are requesting a clinical experience)

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Education & Program Info

Please list the educational institution or program information under which you are requesting a rotation or volunteer experience.

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Enter the name of the school or program through which you will be completing your student or volunteer experience.

When do you want to begin your student/volunteer experience?

When do you want your student/volunteer experience to end?

How many student/volunteer hours are you required to complete with this requested experience?

If you don't know what you exact graduation or program completion date is, please estimate the date. 

Who should we contact regarding your request? This is the person that we will communicate with to ensure a contract and other paperwork is in place. 

Who should we contact at your program/school to coordinate your placement with us?

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Employment History

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Licenses and Registrations

This section is for Medical Residents and Nurse Practitioner placements only. If you are a medical resident or nurse practitioner student, please provide the following:

* Medical/nursing license information
* DEA#
* NPI#

IF YOU ARE NOT AN NP STUDENT OR MEDICAL RESIDENT - SKIP THIS SECTION.

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Authorization and Signature

Disclaimer, Authorization, and Signature

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 termination of my placement by Yakima Valley Farm Workers Clinic (YVFWC). I grant permission to YVFWC to verify and obtain information regarding my employment, school records, criminal history, and license/certification. I hereby release my employers, schools, personal references, and any agencies contacted from any and all liability for damages for providing the information requested. If placed, I release YVFWC from any liability for future references it may provide regarding my affiliation with YVFWC. Placement is contingent upon a satisfactory background check report and full compliance with YVFWC immunization and documentation requirements. I authorize YVFWC to share information contained in my application (such as education and professional experience) with internal stakeholders for inclusion within grant applications for which YVFWC is the grant recipient and for consideration of future employment opportunities. I understand that this application does not guarantee a placement. I consent to electronic submission and storage of this application. I acknowledge my right to withdraw my electronic consent and sign this document in non-electronic format by sending an email to students@yvfwc.org. 

Candidate Sign Off

I certify that all of the information in this application is true and correct as of this date.

Application Review