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:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
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4
5
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31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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2009
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2007
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
(year optional)
Gender:
Choose
Female
Male
Education:
Choose
Associate's Degree
Bachelor's Degree
High School Diploma/GED or Equivalent
Master's Degree
Some High School
Former ProHealth Care Employee:
Choose
No
Yes
School (if currently a student):
Social security #:
Custom 5:
1
2
Employer name:
Employer name:
First name:
First name:
Last name:
Last name:
Street 1:
Street 1:
Street 2:
Street 2:
City:
City:
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
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:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Home phone:
Cell phone:
Email address:
Relationship:
Choose
Brother/Sister
Co-worker
Daughter
Father
Friend
Mother
Neighbor
Sister
Son
Spouse
Availability
Please indicate the days and times you are usually available to volunteer.
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
My availability is:
Choose
Ongoing
Ongoing, except between these dates
Only between these dates
From:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
to:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
I would like to serve up to:
hours:
Choose
Daily
Monthly
One time
Weekly
Please list any additional information regarding your availability.
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.
Musical Instrument:
Clarinet
Flute
French Horn
Guitar
Harp
Piano
Trumpet
Violin
Second language:
German
Hindi
Spanish
Crafts:
Crochet
Knit
Sew
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.
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