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Membership Renewal
Member Information
Name
*
Prefix
First Name
Last Name
Suffix
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Email
*
Verify Email
*
Phone
*
Cell
Gender
Female
Male
Nonbinary
Additional gender information
Birthday
Month and day
Experience & Education
Do you currently have an "active" RN license?
*
Yes
Yes and I'm in nursing school
No, I'm a nursing student
If "YES," Provide the date RN license was obtained
(mm/dd/yyyy)
State currently licensed in
*
Please indicate your nursing school
*
(Note: A student nurse (SN) is an unlicensed student in a nursing program. If this does not apply, please type "N/A".)
Degree studying
*
Year of graduation
Please enter using YYYY format, e.g., 2024
Do you want a mentor
*
Yes
No
Highest degree held
Diploma
Associate Degree
Baccalaureate in Nursing
Masters in Nursing
Masters in Other Fields
Doctorate in Nursing
Doctorate in Other Fields
Nursing employment
Full-time
Part-time
Retired
Unemployed
Employer's Name
Experience in nursing
Less than 5 years
6-10 years
11-15 years
16-20 years
More than 20 years
Primary work setting(s)
Please select all that apply.
Inpatient
Education
Long Term Care
Ambulatory
Community Health
Other work settings
Please list.
Positions held
Please select all that apply.
Clinical
Administration
Research
Education
Informatics
Quality Care
Other positions held
Please list.
Membership in other professional nursing organizations
Please select all that apply.
NBNA
EBNOT
SBNR
ANA
WSNA
KCNA
SNA
NWONL
WCN
NLN
AACN
AMSU
Sigma Theta Tau
Additional other memberships
Please list.
Volunteer
You have a great opportunity to be involved with the organization.
Please identify your area or areas of interest.
Mentorship (student or professional nurse in practice transition)
Grant writing
Program and professional development
Tutor/academic support
List area of interest for tutor/academic support
Committees
Please select all the committees you are interested in.
Publicity/Membership
Education
Ways & Means (fund raising for student scholarships)
Community Outreach (BP Screening, Special Projects, Support Community Projects)
Endowment
History
Other areas of interest
Please list.
Annual Membership Dues
(Memberships are free for nursing students pursuing their initial RN degree.)
Amount
$100
-
Active
$100
-
Active in nursing school
$50
-
Retired
Single-line input
