HH Direct Placement Volunteer

STOP & READ: Complete this application only if you have been instructed by a supervisor or volunteer services staff member. You will be required to enter the department where you have been placed and the name of your Hartford Hospital contact. If you have chosen this application in error, please hit your back browser arrow and make another selection.

***Please create your user name and a secure password***

Secure passwords should contain a minimum of 5 characters with at least one number, one uppercase letter and one lowercase letter.

Volunteers are responsible for the safe-keeping of their passwords.

PLEASE DO NOT SHARE your password with anyone.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Application Information

* I am over the age of 18. I am NOT a High School student

* Family/last name

* First name

* Street Address

* City

State

* Zip/postal

* Home phone xxx xxx-xxxx

Mobile

Highest grade completed

Present School

Course of study

* Emergency Contact Name

* Home phone

Mobile

Please check box if currently employed.

Current or Most Recent Employer

Position Held

Supervisor Name

Business Phone

* In which Department will you be volunteering?

* Name of your Department contact:

* I understand that documentation of an MMR vaccine, history of chicken pox or varicella vaccine, and a recent Tuberculosis (PPD) test will be required to volunteer at Hartford Hospital

* I understand that Flu vaccination is mandatory during flu season.

I hereby authorize Hartford HealthCare, its employees and agents to make recordings of me, whether audio or images, still or moving, and to alter and composite the same without restriction and without my inspection or approval, for use by Hartford HealthCare for any purpose in any and all media now or hereafter known, and to use my name in connection with said use if it chooses. I understand that this consent cannot be revoked, that it is effective in perpetuity, and that I have no expectation of payment in consideration for my authorization. I hereby release and hold harmless Hartford HealthCare, its employees and agents from all claims and liability relating to said recordings. I agree that a copy of this authorization will be as valid as the original.

Agree/Decline