Sponsored Student Membership Form
Greater New York City Black Nurses Association
Sponsored Student Membership Application
I am:
*
Renewing
New
Are you a unlicensed (do not currently have a RN license) nursing student?
*
Yes
No
School of Nursing
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Recruited by:
Gender:
*
Male
Female
Non-binary
Professional Organization Membership:
American Nurses Association
American Association of Critical Care Nurses
National League of Nursing
Chi Eta Phi
American Public Health Association
American Academy of Nursing
Other
Age: (Will Remain Confidential)
*
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Submit
Should be Empty: