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EARN & LEARN
HEALTHCARE INTERNSHIP APPLICATION

First Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Mobile phone number

Can we text you?

Alternate Phone

Last 4 digits of Social Security Number

Email

Please be sure to check your email for communication from us.

High School Information

Student at:

Current grade level

GPA

Anticipated graduation date * required

Are you planning to attend summer school: *

Yes

No

If yes, please list the reason.

Post High School Goals

Career Goal #1

Career Goal #2

Work Experience

Are you currently employed?

Yes

No

Do you have any volunteer experience? *

Yes

No

Volunteer experience

Do you have any special skill training or certificates? *

Yes

No

Skills or certificates

Are you currently enrolled in any academic / training programs that take place over the summer? *

Yes

No

CENTER FOR HEALTHCARE CAREERS
OF SE WISCONSIN

2342 N 27th Street

Milwaukee, WI 53210

info@healthcareerswi.com

Our Partners

Personal data is only stored when voluntarily given by you for a determined purpose e.g. in context of a registration, a survey, a contest, or in performance of a contract. Your individual, identifiable, personal data will not be disclosed to third parties, without your consent. PHONE NUMBERS: Any phone numbers collected through our site, whether through webform or other means, will be used exclusively to communicate with you regarding our services and will never be shared or sold to third parties for promotional or marketing purposes. TELEPHONE COMMUNICATIONS WITH YOU: You agree that our company and its agents may call or text you at any phone number (landline or wireless) that you provide to us, using an automated dialing system and/or a prerecorded message, for marketing services and/or account-related purposes, such as appointment confirmations, service alerts, billing and collection issues or account recovery concerns. You can manage your contact preferences by emailing us, calling us, or replying to text messages with “HELP” for assistance or “STOP” to unsubscribe. Reply “START” to resubscribe. Message and data rates may apply.

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