SQUAN Membership Application

SQUAN Membership Application

Nurse Membership Application Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number

Area CodePhone Number
Country of Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Language

AfrikaansAmharicArabicCameroonian Pidgin EnglishChadian ArabicEnglishFrenchFulfulde (Fula)HausaIgboKikongoKinyarwandaLingalaOromoPortugueseSangoShonaSomaliSwahili (Kiswahili)Tamazight (Berber)TigrinyaTsongaTswanaTwi (Akan)WolofXhosaYorubaZuluOther
Nursing Background
Qualification (Select one)*

Registered Nurse (RN)MidwifeNurse EducatorClinical Nurse SpecialistAdvanced Practice NurseOther
Years of Experience in Nursing*

Less than 1 year1 – 3 years4 – 7 years8 – 15 yearsMore than 15 yearsOther
Current Work Setting (Select one)*

Public HospitalPrivate HospitalPrimary Care/ClinicHome HealthCommunity HealthAcademic/TeachingResearchOther
Department/Unit (Select one)*

Emergency & TraumaIntensive/Critical Care (ICU, NICU, PICU)Medical-SurgicalOperating Room & Perioperative CareMaternity & Newborn CarePediatricsOncology & Cancer CareCardiology & Heart CareNeurology & Stroke CareOrthopedics & RehabilitationInfectious Disease & Isolation UnitsPsychiatric & Mental HealthOutpatient & Specialty ClinicsOther
Interest & Engagement
Why do you want to join SQUAN?
Which areas of patient safety interest you the most? (Select all that apply)*

Maternal & Neonatal SafetySurgical & Anesthesia SafetyEmergency & Trauma CarePediatric & NICU SafetyMedication & Drug SafetyInfection Prevention & ControlDiagnostic Errors & Lab SafetyMental Health & Psychiatric SafetyPatient Identification & Handover RisksCommunication & Safety CultureStaffing & Workload Impact on SafetyHome Care & Community-Based SafetyOther
How would you like to contribute? (Select all that apply)*

Sharing patient safety experiences (anonymously or in discussions)Joining patient safety webinars and trainingBecoming a regional coordinator or ambassadorAssisting with research and advocacyLeading discussions or mentorshipOther
Your Role in the Movement: How Would You Like to Contribute?

SQUAN is built by those who care enough to act. Whether you lead, support, or stay connected—we welcome you.
Would you like to be considered for a leadership role within SQUAN?*

Yes, I am interested in a leadership roleNo, I prefer to participate as a member
Leadership Roles (Volunteer-Based) (Select One). These roles help shape the direction, engagement, and impact of SQUAN. No formal titles required—just commitment, collaboration, and care.

Regional Coordinator – Lead engagement across a language or geographic regionCountry Ambassador – Represent SQUAN in your country and connect membersCommittee Member: Education & Training – Support content for webinars, sessions, and learning materialsCommittee Member: Story Review & Analysis – Help review patient safety stories and extract insightsCommittee Member: Advocacy & Policy – Contribute to SQUAN’s voice on safety policy and reformCommittee Member: Membership & Community Engagement – Help grow, welcome, and support members
Membership Type - (Select One). Choose how you want to engage with SQUAN. Every level matters.

General Member – Stay connected, follow updates, and engage at your own paceActive Member – Attend events, participate in discussions, and contribute to initiativesStudent Member – For nurses and healthcare students who want to learn and grow in patient safety
Do you agree to uphold SQUAN’s mission to improve patient safety and healthcare quality through learning, advocacy, and collaboration? Yes/No

YesNo
Should be Empty:

SQUAN Membership Application

Nursing Background

Interest & Engagement

Your Role in the Movement: How Would You Like to Contribute?