Palliative Care Nurses New Zealand - Membership Application Form

MEMBERSHIP APPLICATION / RENEWAL
(membership period is from 1st July to 30th June)

This application is for INDIVIDUAL membership and is not transferrable

Full name

Postal Address

Telephone - home

- mobile

Email address

Designation

Ethnicity

Other- please specify

Name of current workplace

What is your role

What is your highest qualification

Other - please specifiy

How did you hear about PCNNZ

Other - please specify

What additional activities or functions would you like PCNNZ to provide

Membership Fees:

Please select

Full Membership / one year 2012-2013

$50.00

Full Membership / two years 2012-2014

$100.00

Associate/Student membership

$ 35.00

Other payment options
Please select this option if you wish to pay via internet banking (direct from your bank account)

Pay by electronic transfer

A/C 010961-0125443-00 (Please put your NAME in the reference boxes)

OR Print this form and pay by cheque or money order
Click here to download PDF form to print

Email / Telephone queries to Jan Clark

jan.clark@waikatodhb.health.nz

078398691 or 021761967

Palliative Care Nurses New Zealand Inc. Society
The Kaupapa chosen for Palliative Care Nurses NZ is a Maori saying which is applied to those who offer protection to people at risk, a fundamental aspect of nursing care. It incorporates aspects of a person beyond the physical to include the emotional, spiritual and psychosocial.