Research Volunteers Only

STOP: Complete this application only if you have been accepted as a research volunteer. You will be required to enter your PI's name, department, phone number and email.

Note: We highly recommend that volunteers have their COVID-19 Vaccines and Boosters. Flu shots (during flu season) are mandatory for participation in our volunteer program.

New User Details

User ID

User ID (verify)

Password

Password (verify)

*Highlighted fields are required

* First Name

Middle Initial

* Last Name

Address Information

* Home Address

Apt.#/Suite

* City

* State

* Zip

Phone (Home)

* Phone (Mobile)

* E-mail This e-mail address will be used for all ongoing correspondence.

Emergency Contact

* Name

* Relationship

* City/State/Postal

Phone (Home)

* Phone (Mobile)

Research Placement Information

* Principle Investigator

* Department

* Research Contact Name

* Research Contact Phone

* Research Contact E-mail

* Research.School

Research - Service Term

I understand that any volunteer joining Connecticut Children's during flu season will be required to show documentation of a current influenza vaccination, and an annual vaccination is mandatory for continued participation in the program.

* Current Photo

Parental Consent

Consent for Treatment

By submitting my application, I understand that Connecticut Children's
will consider me for a volunteer position on the basis of the
information I have furnished on this application form, and that
any false, misleading or incomplete statements made by me,
or any omission of material fact shall prevent my volunteering or
shall be cause for immediate dismissal from my volunteer assignment.

I understand that the staff of the Volunteer Services Department
will be calling the references I have listed on this application,
and conducting a background check on me prior to being placed.
As part of the volunteer application process, and at any time
during my volunteer placement, I authorize Connecticut Children's
or any of its affiliates to obtain the record of any conviction for
commission of a felony.

[ clear ]

Please provide a digital signature and click Submit.