Massachusetts School Nurse Organization, MSNO Membership Application Form

Massachusetts School Nurse
Organization, Inc.
Membership Application Form
(MSNO Only)
Membership Year:September 1, 2003 to August 31, 2004

Please register below:

Name (last name first):

E-mail Address (please specify upper/lower case):

Home Address:

Phone (area code):

Town:_________________________________Zip Code:

RN Number:____________________________Expiration Date:

SS#:__________________________________D.O.B:

School Name:___________________________Phone (area code):

School Address:

Town:_________________________________Zip Code:

Please Select Which of the Following Apply:

Employed by:
School Committee:______Board of Health:_______Private School:______Other:___________

School Position:
School Nurse:_____School Administrator:____Practitioner:_____Public Health Nurse:_____Consultant:_____Educator:_____

Area of Practice/Grade Level:
Pre-School:______Elementary:____Middle School:______High School:______Voch/Tech School:_____
Special Education:______Early Childhood:______Charter:______Other:________

Geographic Area of Employment:
Rural:_______Urban:_______Suburban:_________

Number of Schools Served:________________Number of Students Served:___________

Professional Credentialing:
Diploma:______Associate:______BS/BA:______BSN:______MSN:______ M.Ed:_____Advanced Practice Nursing:______Other:____________

DOE Initial Licensure (Prov/Adv Standing):_______________Professional Licensure (Standard):________________

Nursing Certification: NCSN:_____SNP:_____ANCC:_____Other:_____

Membership in other professional organizations: NASN:____MARN:____MNA:____ANA:____ASHA:____NAPNAP:____
MCNP:____APHA:____MTA:____MFT:____AFL-CIO:____Other:__________

Membership Fee: Active: $55.00 Retired: $27.50 Member-at-Large: Contact Membership

Please make check/PO payable to: MSNO

Please return to:
MSNO Membership					OFFICE USE ONLY
c/o Robbie Cobbett					Status_______Region_______Year_____
28 Greenwood Terrace
Swampscott, Massachusetts 01907					Date Processed MSNO________Check#___________
MSNO TIN = 042601335					Pre-payment is expected with all Purchase Orders.
					Application cannot be processed without payment.

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