Connecticut Association of Public Health Nurses

Membership Enrollment Form

(Complete form to submit by email/or print out to fill in by pen to send by mail or fax.)

Please make your check out to CAPHN and mail to the address listed below.
Fee for Regular Membership: $35.00
 (Available to any Registered Nurse currently or formerly engaged in public health nursing practice, education or policy).

Fee for Associate Membership: $20.00
 (Available to any individual with an interest in public health nursing in CT).

PERSONAL INFORMATION

First:              Last: 

Street:  City:    ST:    Zip:

Phone: ( )  Fax: () Email: @

How did you hear about CAPHN, Inc.?      

Please add me to your List Serve Yes  No

I am interested in the following committees: Finance Membership Practice Program Ad Hoc

I would prefer to be contacted: At Home At Work

Comments: 

WORK INFORMATION

Employer/Agency:    Title:

Employer Address:

Professional Designations:

Areas of Practice:

Work Phone: () Work Fax () Work Email: @

Make check Payable to CAPHN and
Mail to: CAPHN, Attention: Virginia Malerba, CT Nurses Association
 377 Research Parkway, Suite 2D, Meriden, CT 06450
Or Fax Application to: 203-238-3437 and then mail check.

Questions contact: dhorvath@nvhd.org