HH Research Applicant

STOP: Complete this application only if you have been accepted as a research volunteer.
You will be required to enter your Hartford Healthcare Supervisors name and Facility Location for this role.

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

* Family/last name

* First name

* Street Address

* City

State

* Zip/postal

* Home phone xxx xxx-xxxx

Mobile xxx xxx-xxxx

* Name of school currently attending N/A if not in school

Highest grade

Course of study

* Emergency Contact Name

* Home phone

Mobile

Currently employed

Are you now or have you ever been employed by Hartford Healthcare?

If yes, please select your facility below

Current / Most Recent Employer

Position Held

Supervisor Name

Business Phone

Required placement information

* Please list the name of the person at Hartford Healthcare who has approved you as a research volunteer

Please select the facility where you will be volunteering

If 'Other' selected above, please list other location here

* I understand that I must provide DOCUMENTED HISTORY of an MMR vaccine (or titer result), history of chicken pox or varicella vaccine (or titer result), Tdap vaccine, PPD test within the past 12 months, FLU vaccine (seasonal). 

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.