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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

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

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