Storage.googleapis.com



VIETNAMESE-AMERICAN NURSES ASSOCIATIONMembership Application FormSubmission is for (check one): ? New Member Application? Member Renewal? Update ProfileType of Membership (check one)? Nurses $45? Students $10 (need proof of enrollment in nursing program)? Associate -other Healthcare Professionals $45Name: Last First MiddleHome Address City State ZipHome PhoneCell Phone EmailEmployer TitleWork Address City State ZipAge: ? < 21? 21-30? 31-40 ? 41-50?51-60 ?61-70? > 70Gender: ? Female ? MaleMarital Status: ? Single ? Married? Divorced ? Widowed? SeparatedEthnicity: ? Asian American ? African American? Native American ? Hispanic? Caucasian (If Asian, select one)? Chinese ? Pacific Islander? Japanese ? Vietnamese? Korean ? Other: Are you interested in serving as an officer and/or a committee member?Committees: ? No ? Yes (f yes, check one of the following)? Awards/Scholarship ? Bylaws ? Development ? Education? Finance? Membership? PolicyOfficer: ? No ? Yes (f yes, check one of the following)? President ? Vice President? Director of Finance ? Communication? Membership ? EducationPlease sign and return this form with your duesAnnual Membership Dues: $Signature: Fund Contribution: (optional) $Date: Total Enclosed: $VANA MEMBER PROFILEI am a (n) ? RN? LVN/LPN? RN Student (Graduation year/degree: /) ? OtherHighest Degree Earned: ? Baccalaureate? Associate? Diploma? Voc-Tech? Doctorate (Specify): ? Master s (Specify): National/State Certification: ? No ? Yes (if yes, please specify):Area (s) of Practice (circle no more than two)? Administration ? Child Health ? Gerontology? Mental Health? Adolescent ? Community Health ? Informatics? Midwifery? Adult Health ? Education ? Managed Care? Research? Anesthesia ? Family Health ? Maternal Health? Women’s Health? Other: Career Experience: ? < 1 year ? 1-5 years? 6-10 years ? 11-15 years ? Over 15 yearsEmployment Status: ? Full-time ? Part-time? Unemployed ? Retired? Student Specialty area (s)(select no more than two)? AIDS/HIV ? Community Health ? Research ? Critical Care ? Education? Women’s Health? Diabetes ? Family Health? Medical (specify): ? Emergency Room ? Neonatal? Surgical (specify): ? Child Health ? Oncology? Other (specify): Work Place? Acute Care Hospital ? Community Health ? Military? Public Health? Ambulatory/Clinic ? Education ? Nursing Home? Self-employed? Association/Foundation? Family Health ? Occupational? Voc-Tech? College/University ? Government Agency ? Private Industry? Other: Type of Position? Clinical Specialist ? Faculty-Academic ? Nurse practitioner? Self-employed? Consultant ? Head Nurse ? Recruiter? Staff-nurse? Dean ? Nurse executive ? Researcher? Supervisor/Coordinator? Educator-clinical ? Nurse manager ? Sales Representative? Other: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download