FANI Group Member Enrollment Form
Thank you for your interest in joining Food Allergy Nurses Interest Group (FANI).  Please complete this form to provide brief information about yourself and your interests in joining FANI group.  This information will also help us create an easy to maintain list of the group members and their contact information for future collaborative initiatives and virtual meetings. Information you provide in this form will not be shared with any other organizations or non-members.
Email *
Please provide your first name *
Please provide your last name *
Please indicate your professional credentials (Example: RN, BSN) *
Please indicate your professional certifications if applicable
Please indicate your state/country of residence (Example: NY, USA)
Please indicate your current position and/or place of employment/practice
I have a professional connection to food allergies
(Please check all that apply)
Are you a member of any of the following allergy related medical/nursing professional organizations?
(Please check all that apply)
I have a personal connection to food allergies
(Please check all that apply)
My personal connection is to the following allergens:
(Please check all that apply)
My interests in joining FANI work-group is the following:
(Please check all that apply)
In this section you can tell us more about yourself, your goals and any other information you prefer to share
How did you hear about this group?  *
Phone number (optional)  *
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