BLACK NURSES ROCK ORLANDO
MEMBERSHIP APPLICATION
Registration Type
*
New member
Renewal
Salutation:
Mr.
Mrs.
Ms.
Dr.
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Birth date:
*
/
Month
/
Day
Year
Date Picker Icon
Credentials:
*
PhD/DNP, RN
MSN, RN
BSN, RN
Student Nurse
Other
Nursing License #
Are you a member of Black Nurses Rock Foundation?
*
Yes
No
Volunteer areas of interest-check all that apply:
Board Member
Administrative Assistant
Health and Wellness Committee
HIV/AIDS Nurse Ambassador
Membership Committee
Mentoring
Scholarship Committee
Nurse Education Committee
Other
How did you hear about us?
*
Friend or colleague
Google
Facebook
Twitter
Instagram
Photo Release Consent:
I hereby grant Black Nurses Rock (Foundation) permission to use my likeness in photographs and/or video in any and all of its publications, including Web space, and in any and all other media, whether now known or hereafter existing, controlled by Black Nurses Rock (Foundation), in perpetuity, and for other use by the Organization. I will make no monetary or other claim against Black Nurses Rock (Foundation) for the use of the photographs and/or video.
*
Yes
No
Disparaging Agreement:
I agree now, and after my term terminates with Black Nurses Rock (Foundation), not to disparage or defame Black Nurses Rock (Foundation) in any respect or to make any derogatory comments, whether written or oral, regarding Black Nurses Rock (Foundation) or its current or former officers, directors, employees, attorneys, agents, or contracting parties, or its business or operations.
*
Yes
No
MEMBERSHIP RULES:
You must be willing to volunteer at least once per quarter
You promise NOT to use to conduct any fraudulent or business activity or have more than one Member Account at any time.
You must sign a copy of the Black Nurses Rock Orlando Chapter Bylaws and Photo release form.
Once you submit your application, we will contact you shortly to complete your membership application.
Thank you!
Annual Total Membership Dues $150.00
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Annual Local Membership Dues
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Item subtotal:
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National Membership Dues
$
100.00
Annual National Membership Dues
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$
0.00
Payment Methods
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