MEMBERSHIP APPLICATION 2008-2009

Suffolk County Association of School Nurses

New: __________ Renewal:__________ Date:__________

 Name:____________________________________________________________________________
Please Print Last name First

Home Address: ___________________________________________________________________

City: ______________________________________ State:___________ Zip: __________

Phone(H): _______________ (W): _______________ (Fax): _______________

E-Mail: (H) ___________________________________ (W) ___________________________________
 
Work Address: ___________________________________________________________________

City: ______________________________________ State:___________ Zip: __________

Memberships: NYSASN/NASN: __________ Union (Name): __________ Other: __________


Please make your check for $20.00 payable to: Suffolk County Association of School Nurses
Membership is September to August.
Current members will receive mailings and a membership card.
Mail payment to: Carol Phelan- Zone Treasurer
25 Iriquois Drive
Brightwaters, NY 11718