2. Last Name*
3. First Name*
4. Washington State Credential*
   -- Select One --MDEMTParamedicRNNPXRAYPACNAPhlebotomistOther
6. Washington State Credential Expiration *
   Washington State Credential Expiration
7. If not able to provide medical care, or your credential is unlisted, what are your skills? *
9. COVID-19 Vaccine
   -- Select One --YesNo

   In accordance with proclamation 21-14.1, all health care providers must provide proof of having the COVID-19 Vaccination.

10. COVID-19 Vaccination Card Scan
12. Basic Life Support Card*
    -- Select One --YesNo
13. Basic Life Support Card Scan
14. Basic Life Support Certification Expiration
    Basic Life Support Certification Expiration
16. Mailing Address*
17. City*
18. State*
20. ZIP*
21. Email*
22. Home Phone*
23. Work Phone*
25. Cell Phone*
26. Training and Training Verification Links
    MRC Training Links

    Complete the MRC trainings at this link. Remember to submit your completion verification to theform link at the bottom of the page.

28. WC #
29. Background Date
30. Expiration Date
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field