Membership Application Haitian American Nurses Association Hudson Valley Chapter Member Information First Name Last Name Email Address Date of Birth (Enter Month & Day) Home Phone Cell Phone Gender —Please choose an option—FemaleMalePrefer not to say Home Address Street Address City State —Please choose an option—NYNJCTPAVTMAOther ZIP Code Professional Information Nursing License Number License State —Please choose an option—NYNJCTPAVTMAOther License Expiry Date Highest Nursing Degree —Please choose an option—DiplomaAssociate Degree (ADN)Bachelor of Science (BSN)Master of Science (MSN)Doctor of Nursing Practice (DNP)PhD in NursingLPNRNNPOther Current Employer/Institution Job Title/Position Type of Membership (Check one Below) New Member (*All New members are required to submit a professional headshot*)Returning MemberAssociate MemberStudent Member Name of School/College Enrolled Payment Information Payment Type ($125 Annually) Payment Method CashCheckElectronic Payment Check Number Electronic Payment Options ZelleCash AppPayPalVenmo Merchandise Sizes T-Shirt Size (*Included with Membership*)* * —Please choose an option—XSSMLXLXXLXXXL Blouse Size (*Separate Cost*) -SELECT AN OPTION- *Please note blouses run one size smallerXSSMLXLXXLXXXLNot Interested Area of Expertise Check all that apply: # of Years as a NurseAddictionAdministrationAmbulatory SurgeryAnesthesiaCase ManagementCommunity HealthCritical CareDialysisEducationEmergency/TraumaForensicsGerontologyHolisticHome HealthHospiceInterventional RadiologyIV InfusionLegal Nurse ConsultantMaternal ChildMedical/SurgicalOccupation HealthOncology/HematologyPediatricPost AnesthesiaPsychiatry/Mental HealthRehabilitationSchool NurseTelehealthTheory/ResearchTransportTravelWound CareOtherCertifications# of Years in Specialty Committees of Interest Check all that apply: BudgetCommunity OutreachElection/Leadership SuccessionEducation ScholarshipFellowshipGala/AwardsGovernanceHealthy LivingHospitalityInternational AffairsMarketing/Social MediaMedical MissionMembership Recruitment & RetentionMentorshipNewsletterPublic Relations/LegislativeRadio Health and Wellness ShowResearch/Grant WritingSponsorship/FundraisingSymposium Emergency Contact Emergency Contact Name Emergency Contact Phone Relationship to Emergency Contact Additional Information How did you hear about HANA Hudson Valley? —Please choose an option—WebsiteSocial MediaFriend/ColleagueProfessional EventAdvertisementOther Referred by (Member Name) Additional Comments or Questions Agreement and Consent I certify that the information provided is true and accurate to the best of my knowledge. I understand that membership is subject to approval by the HANA Hudson Valley board. I consent to receive emails from HANA Hudson Valley regarding membership, events, and organizational updates. I consent to having my contact information included in the member directory (shared only with other members).
