CRITICAL CARE NURSES ASSOCIATION OF THE PHILIPPINES, INC Amount Paid:____________ OR#:______________ DATE:
Membership Application Form ______________
Encoded By: ____________________ jajg / micr □ NEW MEMBER □ RENEWAL 060710 Membership No. ____________ ID Number: _____________ CRITICAL CARE NURSES ASSOCIATION OF THE PHILIPPINES, INC
Last Name First Name Middle 1. To promote and protect the health and welfare of man through the Name science and art of critical care nursing. □ Male □ Female Date of Birth: 2. To formulate, develop strategies and implement standards of _______________________ critical care nursing practice Address: ________________________________________________________________ 3. To provide expertise / assistance to various hospitals in _________________________________________________________________________ establishing critical care units Where are you currently residing? □ Metro Manila □ Province 4. To update knowledge / skills in critical care nursing through Email Address: __________________________________________________________ involvement in Mobile Number: _________________________ PNA No.: _____________________ a. Continuous staff development programs and activities b. Giving assistance in the development of staff development PRC License Number: _____________________Valid Until: programs of related associations, ____________________ c. Dissemination of trends in critical care through newsletter, Employment Data: periodical, publications □ Employed 5. To participate in the formulation of curriculum towards critical care Position: _______________________ Institution: ____________________________ nursing specialization. Area of work: Years of Employment: 6. To encourage, participate, undertake, give assistance to research □ General MS Unit □ Less than 1 year studies relevant to critical care nursing □ Critical Care Unit / ICU □ Less than 2 7. To participate in various international program years 8. To purchase, lease, acquire small properties both real and personal □ Other Area: ____________ □ More than 1 year as may be necessary and conducive to the attainment of the corporation objectives. □ Not Employed Qualification of Members: CCNAPI Trainings Attended: Credit Units Earned: 1. Any registered nurse who has attended at least 20 Credit ______________________________________ ________________________ Education Units of CCNAPI for the current year or have at least 3 ______________________________________ ________________________ months working experience in MS or Critical Care Unit as certified ______________________________________ ________________________ by the immediate superior or headnurse. 2. Resident of the Philippines Educational Data: 3. Member of PNA Highest Educational Attainment: 4. With Current PRC license as a Registered Nurse □ BSN □ MAN / MSN □ Doctorate 5. With good standing in the community School: ____________________________________Year Graduated: ____________ Duties and Responsibilities of a Member: Address: ________________________________________________________________ 1. To obey and comply with the by-laws, rules and regulation that may be promulgated by the association Specialization Interest: 2. To attend all meetings of the association Are interested to pursue critical care specialization? □ Yes □ No 3. To pay membership dues and other assessment of the association Where? □ Locally □ In US □ in UK Benefits of a Member: What area? □ Coronary Care □ Respiratory □ General ICU Care 1. Discounted rates to continuing education programs □ Pediatric □ Other __________________ 2. Access to facilities of the association like books, references and other. What services of CCNAPI do you want to be strengthened? 3. Eligibility to scholarship, grants and awards □ Communication □ Specialty Certification 4. Access to the Members Only information on the CCNAPI Web site □ Continuing Education Programs □ Others _____________________