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ISAPN CONSENT TO SERVE - Program Chair - ISAPN Board of Directors

MEMBER INFORMATION

1.PLEASE COMPLETE THE INFORMATION BELOW(Required.)
2.Which of the following most accurately describe(s) you?
3.Race/Ethnicity (Select all that apply)(Required.)
4.What are your pronouns? This helps us understand the best way to address you
5.EDUCATION - highest level of education(Required.)
6.PLEASE INDICATE YOUR FUTURE APRN SPECIALTY(Required.)
7.PLEASE INDICATE YOUR CLINICAL SPECIALTY i.e. primary care, acute care, women's health, etc(Required.)
8.EMPLOYMENT (Required.)
9.I CONSENT TO HAVE MY NAME CONSIDERED FOR APPOINTMENT/ASSIGNMENT TO THE FOLLOWING POSITIONS.(Required.)
10.Please provide a statement that will inform the Board Members considering the appointment about your goals for the position and as a member of the ISAPN Board of Directors.(Required.)
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
11.Phonetic spelling of your name.
12.If appointed to an ISAPN board of directors, it is my obligation to attend meetings and 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. Code of Ethics for Committee Member Conduct
3. Board of Directors Confidentiality Agreement
4. Conflict of Interest Policy

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