To submit your application, please complete these steps. Fields marked with a red asterisk (*) are required.
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.
. Your 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.
Foreign Languages Spoken
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 email@example.com.
. Resume and Questions
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.
Cover Letter and Resume Text
You can copy and paste your resume or cover letter into the box below.
Upload any additional attachments including documentation of a recent TB test and your immunization records. Immunization requirements include:
• TB test within the last year
• Hepatitis B (only if you will be working with patients)
• Flu vaccine (only during flu season)
If your program coordinator will be sending a letter in good standing outlining your immunization and background check history, please skip this section.
. Work and Education History
Education & Program Info
Please list the educational institution or program information under which you are requesting a rotation or volunteer experience.
. Other History
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
IF YOU ARE NOT AN NP STUDENT OR MEDICAL RESIDENT - SKIP THIS SECTION.
. Review and Submit
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 firstname.lastname@example.org.
Candidate Sign Off
I certify that all of the information in this application is true and correct as of this date.
Candidate eSignature Date