Print and Mail This Form

Date__________________Name:  ________________________________________    

Type of Membership: Check One:  

___Active ($35.00/one year or  $60.00/two years)___  

___Associate ($17.50/one yearor $25.00/two years)

___Retired Lifetime  ($35.00)

Home Information: Address: _________________________________________________

Home Phone: ______________________Home E-Mail: _____________________________

School Information:

County-___________________  Sup. Union:_____________  Grades:____________

School(s) ___________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

School Address_______________________________________________________________

School Phone.___________SchoolFax:_____________

School E-mail:______________________________________________________________

Education:

RN -______ BSN ______ BA ______BS_____ Other______ Certification Type: __________

I would be interested in more information about serving on a committee. Yes_____ No____

Entered School Nursing - year. ________    Total years school nursing _________

Current Membership in: NEA_____AFT____ NASN -_____ANA____ ASHA ____Other___

Dues: Pay for two years and save $10.00!

*Active:   $35.00 /one year  $60.00/two years (RN, currently practicing School Nursing, Voting member)

*Associate:    $17.50/one year $25.00/ two years (RN, serves schools but it not eligible for active membership, may not vote or hold office)     *Retired:   $35.00/lifetime  (may vote but not hold office) ____________________________________________________________________________

NH School Nurse Association Membership

Make Your Check Payable to:

New Hampshire School Nurses' Association:

Sorry Purchase Orders Not Accepted

Mail to: 

Mary Jo Reed, RN, NHSNA Treasurer

123 New Road

Canterbury NH 03224