2024 ISAPN CONSENT TO SERVE - COMMITTEES

MEMBER INFORMATION

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* 1. PLEASE PROVIDE THE INFORMATION BELOW:

First name:

Last Name:

Credentials:

Address:

City/Town:

State:

Zip:

Preferred Email:

Mobile Phone:

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* 2. Which of the following most accurately describe(s) you?

Female

Male

Non-Binary

Transgender

Intersex

I prefer not to say

Other (please specify)

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* 3. Race/Ethnicity (Select all that apply)

American Indian or Alaskan Native

Black or African American

Native Hawaiian or other Pacific Islander

Asian

Hispanic/Latino or Spanish Origin

White/Caucasian

I prefer not to answer

Other (please specify)

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* 4. What are your pronouns? This helps us understand the best way to address you

She/her

He/him

They/them

I prefer not to say

Other (please specify)

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* 5. EDUCATION - highest level of education

DEGREE

SCHOOL

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* 6. PLEASE INDICATE YOUR APRN SPECIALTY

CNM

CNP

CNS

CRNA

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* 7. PLEASE INDICATE YOUR CLINICAL SPECIALTY i.e. primary care, acute care, women's health, etc

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* 8. EMPLOYMENT

EMPLOYER

PRESENT POSITION

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* 9. I CONSENT TO HAVE MY NAME CONSIDERED FOR APPOINTMENT TO THE COMMITTEE(S) INDICATED BELOW:

MEMBERSHIP

FINANCE

AWARDS

PROGRAMS

GOVERNMENT RELATIONS/POLITICAL ACTION COMMITTEE

BYLAWS

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* 10. PLEASE PROVIDE A BRIEF BIO OF YOURSELF AND YOUR PRACTICE.
Provide a summary of your experience and/or interest in serving in the position(s) selected above. Be sure to list other volunteer experiences, board and/or committee service.

Although the pronunciation of many names is obvious, some require special attention. If your name is one that
is pronounced in a special way, please use the key below to advise us how your name should be pronounced.

Indicate either the phonetic spelling of your name OR a familiar word that rhymes with your name.

Phonetic Spelling Instructions

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* 11. Phonetic spelling of your name.

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* 12. If appointed to a committee, it is my obligation to do the work of the position.

If I am unable to fulfill this commitment, I will resign.

Upon appointment, I will receive links to the following forms that must be completed prior to the first committee meeting.
1. Volunteer Participation Agreement
2. Board of Directors Confidentiality Agreement
3. Conflict of Interest Policy

Completion of the line below serves as the electronic signature of the individual completing this form.

Name:

Date:

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* 1. PLEASE PROVIDE THE INFORMATION BELOW:

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* 2. Which of the following most accurately describe(s) you?

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* 3. Race/Ethnicity (Select all that apply)

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* 4. What are your pronouns? This helps us understand the best way to address you

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* 5. EDUCATION - highest level of education

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* 6. PLEASE INDICATE YOUR APRN SPECIALTY

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* 7. PLEASE INDICATE YOUR CLINICAL SPECIALTY i.e. primary care, acute care, women's health, etc

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* 8. EMPLOYMENT

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* 9. I CONSENT TO HAVE MY NAME CONSIDERED FOR APPOINTMENT TO THE COMMITTEE(S) INDICATED BELOW:

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* 10. PLEASE PROVIDE A BRIEF BIO OF YOURSELF AND YOUR PRACTICE. Provide a summary of your experience and/or interest in serving in the position(s) selected above. Be sure to list other volunteer experiences, board and/or committee service.

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* 11. Phonetic spelling of your name.

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* 10. PLEASE PROVIDE A BRIEF BIO OF YOURSELF AND YOUR PRACTICE.
Provide a summary of your experience and/or interest in serving in the position(s) selected above. Be sure to list other volunteer experiences, board and/or committee service.