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OCEAN COUNTY SCHOOL NURSES ASSOCIATION
MEMBERSHIP APPLICATION FOR THE SCHOOL YEAR OF_____________________
Name:_________________________________________________________________
Home Address:__________________________________________________________
City:___________________________________________ Zip Code:_______________
Home/Cell Telephone Number: ( )______________________________________
Email Address:__________________________________________________________
School:________________________________________________________________
School Address:_________________________________________________________
City:___________________________________________ Zip Code:_______________
School Telephone Number ( )__________________________Ext.:____________
School Email Address: ___________________________________________________
School Fax_____________________________________________________________
□ Renewal □ New Member
This is a Change Since Last year circle one Yes/ No
PLEASE CHECK ONE OF THE FOLLOWING
REGULAR MEMBER: Currently full time certified school nurse or supervisor employed by a public Board of Education OceanCounty……………………………………………….$20.00
ASSOCIATE MEMBER: Non-certified school nurse, non-working school nurse enrolled in a certification program, substitute school nurse, school nurse employed by a Board of Education outside Ocean County or by a non-publischool………………………….$15.00
RETIRED MEMBER……………..…………………………………………………$10.00
PLEASE SEND THIS COMPLETED FORM AND CHECK TO:
Lisa Rizzo
Toms River High School South
55 Hyers Street
Toms River
NJ 08753
lrizzo@trschools.com
MAKE CHECKS PAYABLE TO OCSNA, NO PURCHASE ORDERS OR VOUCHERS ACCEPTED!
I am a member of the NJ State School Nurses Association for _______years.
I am a member of the National Association of School Nurses for ______years.
I am interested in helping on a committee_____________________________
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