HH Patient & Family Advisory Council Member

Welcome! Please complete this application only if you have been invited to participate on an Advisory Council. Y ou will need to enter the name of the Advisory Council and the name of the Hartford Hospital contact for this particular Advisory Council. If you feel you have chosen this application in error, please hit your back browser arrow to 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)

I am over the age of 18 and not in High School

* First name

Middle name

* Family/last name

* Address 1

Address 2

* City

* State

* Zip/postal

* On which Advisory Board will you be volunteering?

* What is the name of the Hartford Hospital employee who will be supervising this advisory board?

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.