HH Pet Therapy - Canine Owner Application

***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)

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

Personal

* Family/last name

* First name

* Street Address

* City

* State

* Zip/postal

* Home phone

Mobile

Emergency Contact

* Name

* Best Contact number

Second Contact number

Employment

Current / Most Recent Employer

Position Held

Business Phone

Supervisor Name

Pet Therapy Information

Have you been certified as a team?

* When did you receive your certification?

* Name of certification facility or evaluator

Do you have previous experience as a pet therapy team? If so, where?

* What date are you available to begin volunteering? (A minimum 6-month commitment is required)

Please select your days and times of availability

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

* 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 a flu vaccine is required in 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.

** Please remember to complete the Canine Application for your pet.