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Hartford Hospital Program
Christopher Brechlin
2022-07-05T09:34:20-04:00
Hartford Hospital Program
Please complete this form for participation in our program.
Your Name
(Required)
First
Last
Birth Date
(Required)
MM slash DD slash YYYY
Phone Number
(Required)
Do you have an interest in the medical field and/or non-profit field?
(Required)
Yes
No
We meet every Tuesday starting July 12 and ending Aug 23. Can you commit?
(Required)
Yes
No
Any dates you can't attend?
I understand that I will receive a $50 stipend for EVERY Tuesday that I attend.
(Required)
Yes
No
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)
Yes
No