Request a Service – Wisconsin Nurses Honor Guard

Name of Family Member or Primary Contact Who Is Organizing the Service *

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Last

Those requesting the service need to be either a family member, clergy, funeral director, or other individual directly involved with the funeral planning of the fallen nurse.

Primary Contact Person's Email *

Primary Contact Person's Phone Number *

Name of Nurse We Are Being Asked to Honor *

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Last

All information from here to the bottom of the form pertains to the nurse that we are being asked to honor. Please provide the appropriate answer (if known) with the honoree's details. Thank you.

What is/was the highest level of nuring practiced by the honoree? *

LPN
RN
APRN
DNP/PhD

Where did the honoree work? *

What type of nursing did the honoree specialize in? (ie: ER, ICU, Geriatrics...etc) *

Name(s) and Location(s) of Nursing School(s) Attended

Year(s) of Nursing School Graduation(s) (if known)

Date and Time of Memorial / Funeral Service *

Expected Honor Guard tribute time? *

What time do you anticipate our 10 minute Honor Guard tribute performed? Please note that we arrive 30 minutes before and depart immediately after the tribute and therefore require specific scheduling in order to meet these times. Ideal timing is the transition period from visitation to funeral service.

Name and Phone # of Funeral Home Contact

Location of Service (Address) *

Share a special nursing story with us about the Honoree

Acknowledgement *

Please Note! When requesting an Honor Guard service, you understand that we are volunteers. Attendance of WNHG members at any service is based on member availability and our presence is therefore not guaranteed. Please type "I agree" if you agree and understand this.

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