2008-2009 SCCC-AACN Membership Application



SCCC-AACN Membership Application: Due 9/30/12

SCCC-AACN is a local chapter of the American Association of Critical Care Nurses serving the South Central Connecticut area. All members are eligible to attend chapter continuing education programs, apply for scholarships, and receive chapter correspondence.

All memberships are current from October 2012- September 2013

You MUST be a current member of AACN National to join the Chapter

Member Types

___ Active Membership: Any U.S. Licensed RN $20.00

___ Affiliate Membership: Any LPN/LVN or non-nurse healthcare professional $15.00

___ Emeritus Membership: 55 years or older and past member for 5 years or more $15.00

___ Retired or Disabled: Any member who is no longer practicing because he/she is

permanently retired or disabled $5.00

Name: ________________________________________ Home Phone Number______________

Home Address: _______________________________________________________________

_______________________________________________________________

NOTE: We will send out program flyers & chapter information by email so Please update your email at National AACN: Log onto , click the ’my account’ tab on top right, click update my contact info, update, save and exit.

Hospital/Employer Name: ________________________________________________________

AACN Number: ___________ I am a new member of AACN and have not received my number ___

___ CCRN ___ PCCN ___ CCNS ___ ACNPC ___ CMC ___ CSC

Type of Unit

___ Cath Lab/ IR ___ ER ___ Mixed ICU ___ Pedi ICU

___ CCU ___ Education ___ NICU ___ SICU

___ CTICU ___MICU ___ PACU ___ Tele/ Step down

___ Nurse Manager

Other ____________________________

Return this application to: Carla Hannon Make checks payable to:

By 9/30/12 217 Mountain Rd SCCC AACN

Cheshire, CT 06410

|Official use only: |Cash |Combo with program |AACN |Address |Card Sent |Ambassador |

| | | |Database |Label | | |

|Ck/ # _______ | | | | | | |

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