Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Membership Type *Registered RN | $50Affiliate Member | $35Student Nurse | $15Application Type *First Time ApplicationMembership RenewalName *FirstLastAddress *ApartmentCity *State *Zip Code *Home PhoneOffice PhoneCell PhoneEmail *Are You currently working as a Parish Nurse? *YesNoIf YES, Parish/Faith CommunityPhoneFaxWebsiteParish/Faith Community AddressCityStateZipEmailAs a member of PNMNY, may we include your name & contact information, including email address, in correspondence, publications, and sharing mailing lists with members of PNMNY, Inc? *YesNoCan we share your information with other organizations? *YesNoIf YES, how would you like to be listed?Areas of interest within FCNMNY *MembershipSunshineWebsitePublic Relations/MarketingPrograms/EducationDevelopment/Special EventsNominating Committee/ElectionsOtherIf you selected other, please describeHave you completed the Foundations in Faith Community Nursing course? *YesNoIf YES, WhenWhereAre you interested in attending the Foundations in Faith Community Nursing course? *YesNoSignature of Applicant (type name) *Typing your name in the box below is considered equivalent to your signature and shall be held as such.Date *Please verify you are a real person. * = Submit