2020-2021 SCSNA Application For Membership

Somerset County School Nurse Application

2020-2021
Home Info
Name: *

First Name Middle Name Last Name
Home Address: *

Street Address

Street Address Line 2

City State

Zip Code
Primary/Home Phone: *

Area Code Phone Number
Home E-mail *
Work Info
School:
Grade Level:
School Address:

Street Address

Street Address Line 2

City

Zip Code
Work Phone:

Area Code Phone Number
Work E-mail
example@example.com
Please Note:
- SCSNA communications will be via e-mail, please provide both e-mails.
OUR ASSOCIATION RELIES ON ALL MEMBERS TO ASSIST IN RUNNING THE ORGANIZATION.
I am interested in volunteering for an Executive Board Position. Our School District is interested in hosting a general membership meeting. I have a suggestion for future Meetings/Speakers
My suggestion is:
Membership Types:
- Regular Membership: $50—Certified School Nurse (CSN), RN employed full-time or residing in Somerset County, Substitute, Part-time School Nurse or Retired School Nurse. Members are entitled to voting privileges at general meetings. SCSNA meetings are free for members. Funding for presentations is part of your membership fee. After July 1 $5.00 late fee.
- Student Membership: Enrolled in a program leading to NJ School Nurse Certification: $20. After July 1 $5.00 late fee.
- NJSSNA – NASN Member: Current member of NJSSNA – NASN
I would like to pay by: *

Paypal (Credit Card) Check (Mail) Robin Davitt, 10 Dryden Rd Basking Ridge, NJ 07920
Membership Types
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Regular Membership $ 55.00

Student Membership $ 25.00

Total $ 0.00
Should be Empty:

Somerset County School Nurse Application