PARC Task Force, Inc.

If you prefer, you can print out this form, complete and return it to:

PARC Task Force, Inc.
515 W. Moreland Boulevard, Room CG72
Waukesha, WI 53188
(262) 896-8026
(262) 786-8787 fax

MEMBERSHIP APPLICATION

Date:

Name:

Title/Affiliation:

Street Address:

City:

County:

State or Prov.:

Zip/Postal Code:

Country:

Email Address:

Telephone #: Ext.

Fax #:

Membership category (select one):
If Benefactor/Financial Supporter
(our contribution of $ is enclosed)

Task Force members can serve any area of interest; however, please check those area(s) where you have a particular interest or expertise and describe.
COMMUNITY (AODA, Citizen Advocacy, School/Youth Advocacy)

GOVERNMENT (Law Enforcement, Legislative, Government)

PROFESSIONS (Hospitality, Insurance, Medical, Other Business)

What issues are you interested in working on as a part of the PARC Task Force? Please check all that apply.

Parental responsibility programs	Youth-related activities
Media/Publicity/Promotion	Speakers Bureau
Legislation/Lobbying	Victim impact panel
Membership/Fund Raising
Other (please describe):

Additional Information to assist us in your request:

In 1999...
38 % of the total traffic fatalities were alcohol-related. This is 1 fatality every 33 minutes.

Membership Application
Donor Application
Request for Information
Request for Presentation

Information listed on the PARC Task Force, Inc. website is believed to be current at the time of publication. However, some of the material presented here may have expired since it was posted. Persons should contact a PARC Task Force, Inc. representative whenever relying on dated material or information that is subject to change.