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I am applying for: Clinical Research Internship, Office of Academic Research Simulation Tech, Center for Simulation and Learning Grant Writing Internship, Office of Grants

Please submit your resume and a cover letter below. In your cover letter, please detail why you are applying and anything else we should know about you relating to the role.

Have you ever been convicted of a crime? Yes No

Please describe the nature of the offense, the date of the convictions and the nature of any rehabilitation.

Have you ever been an employee or volunteered at this facility? Yes No

If yes, please indicate dates and department(s).

When are you available to start?

When do you want to start? Summer (June - mid-August cohort) Fall (Sept - mid-December cohort) Spring (mid-January to early May cohort) Other

Do you want to intern remotely or in-person? Remote In-Person

Would you be willing to make a time commitment of 5 hours per week or more? Yes No

If No, please explain:

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Nothing contained in this volunteer application shall be deemed to create an employment contract between Stamford Hospital and myself for either employment or for the providing of any benefit. The granting of an interview shall likewise not create such a contract. No promises regarding my volunteering or inducements to volunteer have been made or offered to me and I understand and agree that no such promises are binding upon Stamford Hospital unless made in writing and signed by the chief executive officer of Stamford Hospital. If I am selected as a volunteer, I understand and agree that I have the right to terminate the volunteer relationship at any time and for any reason and the Stamford Hospital have a similar right. After receiving a conditional offer to participate in a volunteer program, I may be asked to submit to a physical examination that includes a drug test. Any offer to participate in a volunteer program is contingent upon my satisfactory completion of the physical examination, satisfactory references verification, and receipt of a negative drug test result. Such drug test shall be conducted in conformity with the Connecticut drug testing statute (Conn. Gen. Stat. 31-51t to 51aa).I hereby give Stamford Hospital to which I am applying for a volunteer position, and their agents, permission to undertake verification of the information I have provided, to investigate me regarding any criminal records and to investigate my previous employment, educational background and references, and I release them from any liability and responsibility from doing so. Pursuant to section 31-128f of the Connecticut General Statutes, I also hereby release all parties supplying references and other personally identifiable information from any liability or damage whatsoever arising there from. My volunteer application is not complete until I have read and signed the Background Verification Disclosure sheet that will be provided to me in a follow-up once this application is submitted. The information supplied by me on this volunteer application is true and complete to the best of my knowledge. I understand that the discovery of any misrepresentation or omission of facts in the volunteer application may result in revoking my volunteer status.

*My signature below indicates that I understand and agree with all of the above statements

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