Participant Fact Sheet | Wisconsin Promise

Participant Information

Name:*

First Last

Address:*

Street Address Address Line 2 City WI Zip Code

Participant email address:

Phone Number:

Cell Phone Number:

Have you participated in Take Your Legislator to Work before?

I give Wisconsin Promise permission to use my picture from my visit.

A facilitator is someone who is helping you set up your visit.

Name:

First Last

Facilitator email address:

Daytime Phone Number:

Cell Phone Number:

Relationship to participant:

If Other, list relationship:

Do you have permission from your employer to bring your legislator to work?

Your DVR Counselor can help you talk to your employer.

Name of Business:

Business Address:

Street Address Address Line 2 City WI Zip Code

Name of your supervisor:

Your supervisor’s email address:

Your supervisor’s phone number:

Your supervisor's cell phone number:

How many hours per week do you work?

Your job title:

How long have you worked there?

What do you do at your job?

What do you like about your job?

How did you get your job?

Email

This field is for validation purposes and should be left unchanged.