Home
History
Membership
Scholarship
Resources
Announcement
DWF Chapter
Contact
Home
History
Membership
Scholarship
Resources
Announcement
DWF Chapter
Contact
Vietnamese-American Nurses' Association (VANA)
Lorem ipsum dolor sit amet consectetur adipisicing elit. Cum quas delectus dolorum.
VIETNAMESE-AMERICAN NURSES ASSOCIATION
Membership Application Form
Submission is for (check one):
New Member Application
Member Renewal
Update Profile
Type of Membership (check one)
Nurses $45
Students $15 (need proof of enrollment in nursing program)
Associate -other Healthcare Professionals $45
First name
Last name
Middle name
Home Address
City
State
Zip
Home Phone
Cell Phone
Email
Work Address
City
State
Zip
Age
< 21
21-30
31-40
41-50
51-60
61-70
> 70
Gender
Male
Female
Marital Status
Single
Married
Ethnicity
Asian American
African American
Native American
Hispanic
Caucasian
(If Asian, select one)
Chinese
Pacific Islander
Japanese
Vietnamese
Korean
Others:
Are you interested in serving as an officer and/or a committee member?
Committees:
No
Yes (f yes, check one of the following)
Awards/Scholarship
Bylaws
Development
Education
Finance
Membership
Policy
Officer:
No
Yes (f yes, check one of the following)
President
Vice President
Director of Finance
Communication
Membership
Education
Policy
Annual Membership Dues:
Fund Contribution: (optional)
Please sign and return this form with your dues(Signature)
Date
Total Enclosed
VANA MEMBER PROFILE
I am a (n)
RN
LVN/LPN
RN Student
Other
Highest Degree Earned
Baccalaureate
Students $15 (need proof of enrollment in nursing program)
Associate -other Healthcare Professionals $45
Doctorate (Specify):
Master s (Specify):
National/State Certification
No
Yes (if yes, please specify):
Area (s) of Practice (circle no more than two)
Administration
Adolescent
Adult Health
Anesthesia
Other:
Child Health
Community Health
Education
Family Health
Gerontology
Informatics
Managed Care
Maternal Health
Mental Health
Midwifery
Research
Women’s Health
Career Experience
< 1 year
1-5 years
6-10 years
11-15 years
Over 15 years
Employment Status:
Full-time
Part-time
Unemployed
Retired
Student
Specialty area (s)(select no more than two)
AIDS/HIV
Critical Care
Diabetes
Emergency Room
Child Health
Community Health
Education
Family Health
Neonatal
Oncology
Research
Women’s Health
Medical (specify):
Surgical (specify):
Other (specify):
Work Place
Acute Care Hospital
Ambulatory/Clinic
Association/Foundation
College/University
Other
Community Health
Education
Family Health
Government Agency
Military
Nursing Home
Occupational
Private Industry
Public Health
Self-employed
Voc-Tech
Type of Position
Clinical Specialist
Consultant
Dean
Educator-clinical
Other
Faculty-Academic
Head Nurse
Nurse executive
Nurse manager
Nurse practitioner
Recruiter
Researcher
Sales Representative
Self-employed
Staff-nurse
Supervisor/Coordinator
Submit