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2022 NJENA Delegate Application
Northern Chapter
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* Indicates required question
Email
*
Your email
First Name
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Your answer
Last Name
*
Your answer
ENA Member ID
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Your answer
Address
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Are you a member of the NJENA Northern Chapter?
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Yes
No
Not Sure
Are you an currently active member of NJENA at the state or chapter level?
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Yes
No
Do you hold one of the following officer positions at the chapter level?
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President
President Elect
Treasurer
Secretary
Immediate Past President
None of the above
Have you attended 50% of the NJENA State Council meetings in the last year?
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Yes
No
Have you attended 50% of the Chapter meetings in the last year?
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Yes
No
Have you served in an elected position at the Local, State, or National level during the past three years? If so, please specify.
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Your answer
Have you served in an appointed position at the Local, State, or National level during the past three years? If so, please specify.
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Your answer
Have you participated in at least one (1) of the following activities related to emergency nursing since the previous General Assembly: (list what you did)
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Lecturer (other than that which is required by job)
Projects (public education, chapter fund-raising, etc.)
Research in emergency nursing
Publish on topics related to emergency care
Chapter delegate to last ECC Annual Meeting
Other activities
Required
Please explain above answer by listing what you have done
Your answer
Are you interested in being mentored as a delegate?
Yes
No
Maybe
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I verify that the above information is correct. I understand the roles and responsibilities of a delegate and/or alternate in ENA General Assembly. Failure to comply with the above responsibilities will affect eligibility for reimbursement.
*
Yes
Required
A copy of your responses will be emailed to the address you provided.
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