Nurses Membership Registration Form (GF)

Step 1 of 7

14%

Section Break

Contact Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth

MM slash DD slash YYYY

Contact Preference(Required)

Phone

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Organization Name(Required)

Job Title(Required)

LinkedIn Profile

Demographics

Race / Ethnicity(Required)

What is your primary language spoken?(Required)

Other:(Required)

What type of area do you reside in?(Required)

Are you a U.S. military veteran?(Required)

Yes

Prefer not to say

Includes individuals who have served in any branch of the U.S. Armed Forces, including the National Guard or Reserves, regardless of discharge status.

Do you identify as a person with a disability?(Required)

Yes

Prefer not to say

This may include physical, sensory, cognitive, intellectual, developmental, or mental health disabilities, whether visible or invisible.

Clinical Identity

State(s) of Licensure(Required)

Years in Practice(Required)

Primary Practice Setting(Required)

Hospital

Outpatient clinic

Community health center

Private practice

Academic medical center

Long-term care

Telehealth

Other

Clinical Specialty / Focus Area(Required)

Nursing Credential(s)(Required)

LPN / LVN

BSN

MSN

APRN

CNS

CNM

CRNA

Other nursing credential

Other nursing credential(s):

Health Equity & Disparities Focus

Which areas of health disparities or health equity does your work or interest focus on?(Required)

Social determinants of health

Rural health

Community engagement

Health literacy

Health systems improvement

Workforce development

Equity research

Other

It other:

Please share a brief description of your work, experience, or interest in health disparities or health equity.(Required)

Opportunities of Interest

What types of opportunities are you interested in?(Required)

Policy briefings

Research collaborations

Speaking opportunities

Advisory roles

Community engagement

Mentorship

Volunteering

Networking

Other

Other:

Do you have interest in joining a NAEHD research committee?(Required)

Yes

If yes, which research committee are you interested in joining?(Required)

Barriers & Access

Maternal Health Outcomes

Chronic & Rare Disease

Counseling & Mental Health

Under & Uninsured

Story Sharing & Visibility

Would you like to be contacted about opportunities to share your story publicly?(Required)

Yes

Maybe

If you’re open to sharing, what types of storytelling opportunities interest you?

Consent & Acknowledgement

Membership Dues Acknowledgment(Required)

I understand that the Nurses membership dues become non‑refundable after 48 hours. Any intent to cancel must be submitted within 48 hours of registration to membership@naehd.org

Communication & Information Use — Consent to Receive(Required)

I consent to receive communications from NAEHD related to my membership, including advocacy opportunities, events, newsletters, updates, and curated resources from partner organizations.

Communication & Information Use — Data Use Acknowledgment(Required)

My information will only be used to support my participation as a Nurse member and to provide relevant membership communications. My information will not be shared outside of NAEHD.

This field is hidden when viewing the form

Membership Tier

This field is hidden when viewing the form

Membership Types

Payment

Membership Level

Nursing Professional

Total

Credit Card

CAPTCHA

Nurses Membership Registration Form (GF)

Nurses Membership Form

Section Break

Contact Information

Demographics

Clinical Identity

Health Equity & Disparities Focus

Opportunities of Interest

Story Sharing & Visibility

Consent & Acknowledgement

Payment