Registration Form


Select a Username and Password

Username:

Password:

Confirm Password:

 

Personal Information

Surname:

Last Name:

First Name:

Middle Initial:

Street/PO Box:

City:

US State or Foreign Country:

Zip:

Phone:

Email:

Credentials:

OK to list name on Members Section?:

Work Place Information

Employer:

Street/PO Box:

City:

State:

Zip:

Phone:

Email:

 

Membership Type

Full-Voting Member (RN) $95.00

Affiliate Member (Non-nursing only) $75.00

Student (Nursing or health related field) $65.00

 

License Information

RN License State:

License Number:

Other Discipline:

State:

 

Demographic Information

Gender:

Job Setting:

Position:

Practice Area:

Years in Bariatric Nursing:

Highest Degree Attained: