Thank you for your interest in volunteering for PS-WA! Please take a few minutes to complete the form below only after completing the Volunteer Interests Survey on our website. All responses are kept confidential.
Please allow two weeks for your application to be processed, including reference checks. If you have any questions or concerns, please contact Victoria Cherniak, Program Manager, at
. Thank you!
Help us get to know you!
First and Last Name
Home Phone/Cell Phone/Work Phone
What pronouns do you prefer?
Ethnicity & Race
Hispanic or Latinx
Non-Hispanic or Non-Latinx
Black American/African American
American Indian/Native Alaskan/First Nation Peoples
Hawaiian Native/Pacific Islander
Three or More Races
Emergency Contact Information
Please provide the name, phone number, and relationship of the person you'd like for us to contact in the event of an emergency.
Name (First and Last)
Have you ever been convicted of a felony?
Do you have any current pending criminal charges against you?
If "Yes", please explain:
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This form was created inside of Kaleidoscope Wellness PLLC.