HPNA Membership Application   
 
This online membership process requires credit card payment at time of application submission.  HPNA membership fees can be found at this "Membership Levels / Fees" link.  If you do not wish to pay by credit card, please use our hard-copy application, which can be downloaded by clicking here

Upon submission of this application you will be re-directed to the HPNA Checkout page, where you will be asked for your credit card information (Visa, MasterCard, American Express are accepted).   A payment receipt with your HPNA member # and password will be emailed immediately, and an official welcome email will be sent by the next business day.

Please enter as much information as possible.  The more we know about our members, the better we can serve them! them!

 
      
  (* indicates required field)
 
 
   Personal Information   
 
First Name *
Last Name *
Middle Initial
 
 
Credentials
Date of Birth *
 (xx/xx/xxxx)
 
 
Home Address (Line 1) *
Home Address (Line 2 - if applicable)
 
 
Home City *
Home State and Zip + 4/Postal Code *
 
Home Country *
 
   Employer Information   
 
Employer
Employer Phone
 
 
Employer Address (Line 1)
Employer Address (Line 2 - if applicable)
 
 
Employer City
Employer State + Zip + 4/Postal Code
 
Employer Country
 
   Contact Information   
 
Home Phone *
Cell Phone
For mailings, which address should be used?
 
  Email is used for e-newsletter, membership confirmation, and organizational announcements.  HPNA does not rent/sell email addresses.  
 
Primary Email Address *
Please re-enter Primary Email address (for accuracy)
 
 
Secondary Email Address
Please re-enter Secondary Email address (for accuracy)
 
   Preferences   
 
I wish to receive the free e-newsletter
HPNA may include my contact information in the "Members Only" Online Directory of HPNA
HPNA may distribute my contact information for purposes unrelated to HPNA activities
I will access JHPN online (and not receive a mailed copy) in the "Members Only" area of the HPNA website
 
   Professional Information   
 
Professional Background
Type of Practice   if Other, please specify:
Highest Education
 
   Professional Demographics   
 
Which best describes the nature of your practice?  
if Other, please specify:
Total years in your profession
Total years in H/P care
Primary Role  
if Other, please specify:
Primary Employer  
if Other, please specify:
Primary Practice Setting  
if Other, please specify:
Primary Age Group served
 
   Optional Information   
  What membership benefits do you value most (select up to 3)  
 
Benefit 1
Benefit 2
Benefit 3
if Other, please specify:  
 
 
If you are a member of an HPNA chapter or provisional group, please select it from the list:
How did you learn about HPNA?  
if Other, please specify:
Gender
Ethnicity  
if Other, please specify:
 
   Membership Category   
 
RN Voting member / JHPN, online JPM
Senior RN **(RNs, 70 or older, no longer working in nursing) Voting member / JHPN, online  JPM
RN Student ** (Full-Time student, RN licensed)   Voting member / Online JHPN, online  JPM
LP/VN Non-voting member / JHPN, online  JPM
Nursing Assistant Non-voting member / NA nwsltr, online  JPM
Student Nurse **(Full-Time Student, Non-Licensed RN)   Non-voting member / online  JPM
Associate (non-RN; ex: MSW, clergy, MD)   Non-voting member / JHPN, online  JPM
 
  ** may require proof of age or program enrollment   
   Notice:  5.2% of your membership dues are allocated to lobbying costs, and are therefore nondeductible as a business expense.  Please consult your tax advisor for further advice.