Hartford Hospital Program

Please complete this form for participation in our program.

Your Name(Required)

First Last

Birth Date(Required)

Phone Number(Required)

Do you have an interest in the medical field and/or non-profit field?(Required)

We meet every Tuesday starting July 12 and ending Aug 23. Can you commit?(Required)

Any dates you can't attend?

I understand that I will receive a $50 stipend for EVERY Tuesday that I attend.(Required)

I understand that if I miss a Tuesday, I will not be paid. If I miss more than 2 Tuesdays, I will be removed from the program.(Required)