ANS Membership Application
Name: _________________________________________
B-day: ________________________
Home Address:
______________________________________________________________________________
City:__________________________________State:____________________Zip:_____________
Phone Number: __________________________________ (with area code)
Emergency Contact Information:
______________________________________________________________________________
______________________________________________________________________________
Semester in Nursing School (circle one):
1st
2nd
Interesting in Having a Mentor – 1st & 2nd semester students (circle one):
3rd
Yes
4th
No
I, _____________________________________________________, understand that $15 dollars in
memberships dues are to be paid for every 2 semesters you are a member (or $7.50 per semester).
These dues are non-refundable. A $25.00 returned check fee will be charged to your student
account if your check does not clear. I understand that I will need to request a graduation cord once
I have earned 32 club points.
Printed Name: ___________________________________________
Signature: _______________________________________________
Date: ______________
Official Use Only
Dues Paid on: __________________________________
Method:
Cash (Change given: ________________)
32 points Earned on: ____________________
Check (Number: _________________)
Graduation Cord Ordered:
Approval for Cord: __________________________________________________
Yes
No
Date: ________