Volunteer Application Form

Please complete this application form if you are interested in becoming a ProHealth Care volunteer. Once you complete the form, click the submit button at the bottom.

Name and address

First name:

Last name:

Middle name:

Nickname:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

(year optional)

Gender:

Education:

Former ProHealth Care Employee:

School (if currently a student):

Social security #:

Custom 5:

1

2

Employer name:

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Please list the type of work you did at each employer.

Emergency Contact

Please list at least one emergency contact.

First name:

Last name:

Street 1:

Street 2:

City:

State:

Zip:

Home phone:

Cell phone:

Email address:

Relationship:

Availability

Please indicate the days and times you are usually available to volunteer.

Potential Placement Information

Please answer the following questions that will assist in identifing placement opportunities that match your skills and areas of interest.

Why do you want to volunteer at ProHealth Care?

Volunteer Experience

Please list any past volunteer experience and provide a brief description of what type of work you did.

Area of Interest

Please list areas where you would like to volunteer and the type of work you would like to do during your experience at Waukesha Memorial.