Welcome to The Hospital of Central Connecticut Volunteer Application Page

Online Adult Application (18 or over NOT in High School)

I am over the age of 18. I am NOT a High School student
Personal
Last name
First name
Middle name
Application date
Street Address
City
State
Zip/postal
Home phone
Mobile
E-mail
Education
Course of study
School
Highest education
Additional School
Additional Field of study
Work Experience
Currently employed
Current / Most Recent Employer
Position Held
Dates of employment
Previous Employer
Position Held
Dates of employment
I have previous volunteer experience
City/ST
Name of Organization
Volunteer Role
Volunteer Dates
Emergency Contact
Mobile
Home phone
Contact name
Relationship
Please provide two academic, professional or volunteer references who are not related to you
References
Reference Name
Address
Phone
Email Address
Relationship
Reference
Address
Phone
Email address
Relationship
Have you ever been convicted of or had a finding rendered by a court concerning a crime?
Yes
No
If yes please specify below:
How did you hear about our program?
Please list any special skills or interests as they apply to the volunteer position, including any languages spoken
Do you currently hold any certification or licensure? if yes please list below:
Check here if you are required to do Community Service
If yes, how many hours do you need to complete?
By what date do you need to complete your hours?
Volunteer Agreement
I authorize the Volunteer Office to contact the references provided by me to obtain the information pertinent to my responsibilities as a volunteer at The Hospital of Central Connecticut.

I agree to abide by the policies and regulations of The Hospital of Central Connecticut and the Volunteer Services Department and to participate in orientation and training required by the hospital.

I will hold as absolutely confidential all information that I may obtain directly or indirectly concerning patients or personnel and not seek to obtain confidential information from a patient.

I understand that I may be dismissed from my duties if I fail to comply with hospital policies and procedures, willful wrongdoing or negligence and/or performing duties outside of my service guidelines, inappropriate behavior, or any other circumstances deemed contrary by the Manager of Volunteer Services to the best interests of the hospital.

I certify that the facts set forth in this application are true and complete to the best of my knowledge.

I understand that if I am accepted into the Volunteer Services program, false statements may result in my dismissal.

I understand that I am expected to inform the Department of Volunteer Services of any significant change in my health status that would negatively impact on my ability to perform the tasks to which I am assigned.
Agree
I understand that beginning with the coming flu season, influenza vaccination (flu shot) will be required for all volunteers.
* If you are a high school student completing the adult application, it will be rejected . Please see our website for teen application information.