1.Personal Information

Name

Credentials

Place of Employment

Which Nursing Organizations are you currently a member of?

Board(s) currently serving on

2.In your view, why is it important for nurses to serve on boards?

3.Share an experience of how you have made an impact serving on boards.

4.What advise do you have for nurses serving on a board?

5.Please upload a recent photograph of yourself

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6.Consent to be interviewed – Nurses on Boards Coalition

I hereby consent to being photographed, interviewed, videotaped/filmed and give permission for the above materials to be used in marketing materials for the Nurses on Boards Coalition.

I agree that the Nurses on Boards Coalition may use the negatives, prints or video prepared from my photographs, words or written materials reflecting my interview for any purposes and in such manner as they may choose, including but not limited to use in informational or promotional materials about the Nurses on Boards Coalition, including: News coverage by television, newspaper, radio, internet or other media, video news releases, advertisements/marketing materials, internal and external video productions.