APPLICATION FOR ASSOCIATE MEMBERSHIP
PROFILE FOR FACULTY
Membership Year: September 1-August 31

Name:____________________________________________________________________________________

Mailing Address:____________________________________________________________________________

_________________________________________________________________________________________

City:_______________________________________ State:___________  Zip:___________________________

Tel:___________________ Fax:___________________ Email:________________________________________

Name of Institution & NP Program:_______________________________________________________________

Title/Position (i.e. Professor, Associate Professor, etc):_________________________________________________

Specialty area of NP Program: 

	Acute Care    Adult    Family    Gerontological    Pediatric

	Psych-Mental Health        Women's Health      Other (specify):______________________________

Location of NP Program: 

	School of Nursing    School of Medicine    Other (describe):________________________________

Does your institution have an Academic Nursing Center?	Yes	No

Your percentage of time in faculty position (e.g. 100%, 50%)_____________________

Your highest level of education: 

	Baccalaureate  Masters   Doctorate   Post-Masters   Other (specify):_____________________

Number of years in current teaching position:______________

Total number of years as a nurse practitioner:______________

	NP Specialty area of practice (e.g., family):_________________________________

	If not an NP, please specify your APRN or other health care role:_________________________________

Do you practice clinically?   Yes   No

 		          ¯ 

		As part of teaching job

		As a separate (paid) job

		Other (specify):____________________________________________ 

		Approximate numbers of hours per week in clinical practice:___________

		Please describe your practice setting and type of practice:__________________________________

		______________________________________________________________________________

Are you involved in research activities?  Yes   No

	 		      ¯ 

		What is you current project?_________________________________________________________

		_______________________________________________________________________________

Please answer the following questions to help us track the diversity of our membership.

	Gender:	Female   Male

	Age:	25-29  30-39  40-49  50-59  60-65  66+

Please identify your race/ethnicity.  Select one or more as appropriate.

American Indian or Alaska Native	Asian		Black or African American

Hispanic or Latino	Native Hawaiian or other Pacific Islander	White

MEMBERSHIP DUES: $100.00

SIG Membership (Optional): Join one or more of the SIGs to engage in targeted discussion and activities with other faculty.  Additional membership fee of $15 per SIG.

Academic Nursing Center  Acute Care  Distance Learning  Gerontological  International  Program Director

Psych-Mental Health NP   End of Life Care

Recruited by:_______________________________________________________________________________

Associate membership is available to all interested persons. Each Associate member receives membership communications and membership discounts but is not eligible to vote or to hold an elected position.

 

Please complete application and return with check payable to:

NONPF

1522 K Street, NW, Suite 702

Washington, DC  20005