Colonial Residence Assisted Living is a local family-owned non-profit facility. Our goal is to provide the best comfort, care, & safety for our residents.

Printable Application Forms

Download the PDF below and bring it to our office, or fill out the online applicaiton.

Call Us

Phone: (360) 736-1551

Our Location

2700 Colonial Dr,
Centralia, WA 98531

Hours of Operation

Monday-Friday, 9am – 4pm

Online Application Forms

Employment Application

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Step 1 of 2

Personal Information

Applicant Name
Present Address
Permanent Address
Are you 18 years of age or older?

Volunteer Application

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Volunteer Contact Information


Emergency Contact Information

Emergency Contact Name

Volunteer Details

Which days of the week are you available?
What time of day do you prefer?

Volunteer Authorizations

I have read and agree to the following.
Background Check
Liability Wavier

Background Check Authorization

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Step 1 of 3
Legal Name
Required: Legal name as it is listed on your driver's license or government-issued photo identification (ID).
Alias Name
Other alias first, middle, and last names you have used.
I authorize BCCU to leave a detailed message.
By checking this box, I consent to and authorize BCCU to email my confidential and sensitive background check information, including a fingerprint rap sheet (if applicable), to the email address I have provided. By not checking this box, BCCU will use the mailing address provided to send me my background check information.
Have you lived in any state or country other than Washington state within the last three years (36 months)?
Mailing Address
Mailing address where we can send you confidential information.
Is your physical address the same as your mailing address?

Section 2. Self Disclosure

Self-disclosure questions for all convictions and pending charges from any state or jurisdiction. You must answer questions 11A through 14. Attach Page 2 if you have crimes or pending charges. See instructions.
11A. Have you been convicted of any crime? If Yes. complete Page 2, Section 3
11 B. Do you have charges (pending) against you for any crime? If Yes. complete Page 2, Section 4
Has a court or state agency ever issued you an order or other final notification stating that you have sexually abused, physically abused, neglected, abandoned, or exploited a child, juvenile, or vulnerable adult?
Has a government agency ever denied, terminated, or revoked your contract or license for failing to care for children, juveniles, or vulnerable adults; or have you ever given up your contract or license because a government agency was taking action against you for failing to care for children, juveniles, or vulnerable adults?
Has a court ever entered any of the following orders against you for abuse, sexual abuse, neglect, abandonment, domestic violence, exploitation, or financial exploitation of a vulnerable adult, juvenile, or child?.

Permanent vulnerable adult protection order/ restraining order, either active or expired .

Sexual assault protection order .

Permanent civil anti-harassment protection order, either active or expired .

Date / Time

I am the person named above. If I do not tell the whole truth on this form, I understand I can be charged with perjury, and I may not be allowed to work with vulnerable adults, juveniles, or children. I understand and agree my signature in the box below means:

- I give DSHS permission to check my background with any governmental entity and law enforcement agency.
- My background check result may include prior self-disclosure information and fingerprint results that are contained in the DSHS Background Check System, and that this information will be reported as allowed by federal or state law.
- If a final finding is identified, DSHS will report only my name and that a final finding was identified on the background check result.
- DSHS will give my background check result to the persons or entities requesting my background check, and those persons or entities may release my background check results to other persons or entities when the law authorizes or requires DSHS to do so. Fingerprint rap sheets are provided if allowed by federal or state law.