Victim/Witness Notification Program Enrollment Request Form

To enroll in the Victim/Witness Notification Program, complete and submit the registration form below. When you submit this information, it will be a secure transmission and remain confidential. The person who victimized you will not know you are being notified and will not have access to your address, email or telephone number.

DSHS wants to be able to contact you quickly and reliably prior to the release of the patient/resident from DSHS custody. Please choose the most effective method of notifying you below. In the event of an escape, we will contact you by the most expedient means reasonably possible. It is your responsibility to keep us updated on your current address, email, and phone numbers.

* Indicates Response Required

*Your Name:

*Email:

Street or Mailing Address:

City:

State:

Zip Code:

Home Telephone: 123-123-4567

Message Telephone: 123-123-4567

*Your Role in this Case: Check One
Victim
Witness
Next of Kin to Victim
Guardian of Minor Victim
Advocate of Victim
Lawyer of Victim

OFFENDER INFORMATION

* First Name

Middle Name

* Last Name

Birth Date(if known): (mm/dd/yyyy)

Sentence Date (if known): (mm/dd/yyyy)

Case Number (if known):

County of Conviction:

Offense:

Comments:

DECLARATION

Carefully read the following statement and select Accept or Reject.

I declare that the information I am providing on this enrollment form is true, correct, and complete to the best of my knowledge. I understand that it is my responsibility to update my records with the Victim/Witness Notification office if I change phone numbers and/or addresses.

I have read the statement above and agree to the terms listed.

Note: If you reject this declaration, you will not be enrolled the Victim/Witness Notification Program. Please contact us at (800) 422-1536 or email vwn@dshs.wa.gov if you have any questions.

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