CRITICAL CARE NURSES ASSOCIATION OF THE PHILIPPINES, INC Amount Paid:____________ OR#:______________ DATE:

Membership Application Form ______________

Encoded By: ____________________ jajg / micr
□ NEW MEMBER □ RENEWAL 060710
Membership No. ____________ ID Number: _____________ CRITICAL CARE NURSES ASSOCIATION OF THE PHILIPPINES, INC

Name: __________________________________________________________________ Purposes:

Last Name First Name Middle 1. To promote and protect the health and welfare of man through the
Name science and art of critical care nursing.
□ Male □ Female Date of Birth: 2. To formulate, develop strategies and implement standards of
_______________________ critical care nursing practice
Address: ________________________________________________________________ 3. To provide expertise / assistance to various hospitals in
_________________________________________________________________________ establishing critical care units
Where are you currently residing? □ Metro Manila □ Province 4. To update knowledge / skills in critical care nursing through
Email Address: __________________________________________________________ involvement in
Mobile Number: _________________________ PNA No.: _____________________ a. Continuous staff development programs and activities
b. Giving assistance in the development of staff development
PRC License Number: _____________________Valid Until: programs of related associations,
____________________ c. Dissemination of trends in critical care through newsletter,
Employment Data: periodical, publications
□ Employed 5. To participate in the formulation of curriculum towards critical care
Position: _______________________ Institution: ____________________________ nursing specialization.
Area of work: Years of Employment: 6. To encourage, participate, undertake, give assistance to research
□ General MS Unit □ Less than 1 year studies relevant to critical care nursing
□ Critical Care Unit / ICU □ Less than 2 7. To participate in various international program
years 8. To purchase, lease, acquire small properties both real and personal
□ Other Area: ____________ □ More than 1 year as may be necessary and conducive to the attainment of the
corporation objectives.
□ Not Employed Qualification of Members:
CCNAPI Trainings Attended: Credit Units Earned: 1. Any registered nurse who has attended at least 20 Credit
______________________________________ ________________________
Education Units of CCNAPI for the current year or have at least 3
______________________________________ ________________________
months working experience in MS or Critical Care Unit as certified
______________________________________ ________________________
by the immediate superior or headnurse.
2. Resident of the Philippines
Educational Data:
3. Member of PNA
Highest Educational Attainment:
4. With Current PRC license as a Registered Nurse
□ BSN □ MAN / MSN □ Doctorate
5. With good standing in the community
School: ____________________________________Year Graduated: ____________
Duties and Responsibilities of a Member:
Address: ________________________________________________________________
1. To obey and comply with the by-laws, rules and regulation that
may be promulgated by the association
Specialization Interest:
2. To attend all meetings of the association
Are interested to pursue critical care specialization? □ Yes □ No 3. To pay membership dues and other assessment of the association
Where? □ Locally □ In US □ in UK Benefits of a Member:
What area? □ Coronary Care □ Respiratory □ General ICU Care 1. Discounted rates to continuing education programs
□ Pediatric □ Other __________________ 2. Access to facilities of the association like books, references and
other.
What services of CCNAPI do you want to be strengthened? 3. Eligibility to scholarship, grants and awards
□ Communication □ Specialty Certification 4. Access to the Members Only information on the CCNAPI Web site
□ Continuing Education Programs □ Others _____________________