Membership

Membership Application

Please print, fill out and mail or fax this form to:

Association of Rehabilitation Nurses
PO Box 3781
Oak Brook,IL 60522
800/229-7530
Fax: 877/734-9384

Name
Credentials
Place of Employment
Title
Preferred mailing address	Office    Home
Street address
City/State/Zip
Preferred Telephone	Business    Home
	()
Fax	()
E-mail
Recruited By

Present position held (choose one)
1  Staff nurse or primary nurse
2  Nurse manager
3  Nursing administrator
4  Staff development educator
5  Academic educator
6  Clinical nurse specialist (MSN)
7  Nurse clinician
8  Community nurse or home health nurse
9  Insurance-related nurse consultant
10  Consultant
11  Case manager (outside facility)
12  Case manager (within facility)
13  Nurse practitioner
14  Nurse liaison
15  Researcher
16  Retired nurse
17  Not currently employed
18  Full-time student
19  Other (specify)

Highest degree completed (choose one)
1  Associate in nursing
2  Diploma
3  Baccalaureate in nursing
4  Master’s in nursing
5  Doctorate in nursing
6  Associate in another field
7  Baccalaureate in another field
8  Master’s in another field
9  Doctorate in another field (specify field)

Years of experience in rehabilitation nursing (choose one)
1  Less than 1 year
2  1-3 years
3  4-6 years
4  7-10 years
5  11-15 years
6  16-20 years
7  More than 20 years

Current practice setting (choose one)
1  Hospital/medical center (with rehabilitation unit)
2  Hospital/medical center (without rehabilitation unit)
3  Freestanding rehabilitation facility (may be affiliated with hospital)
4  Long-term care facility
5  Subacute facility
6  Department of Veterans Affairs medical center
7  Insurance company
8  State agency
9  Home health agency
10  Educational institution
11  Private company/private practice
12  Not currently employed
13  Other (specify)

Current clinical practice interest
1  Arthritis/rheumatic disorders
2  Burns
3  Cardiac
4  General rehabilitation
5  Head injury
6  Musculoskeletal
7  Neurological
8  Oncology
9  Pain
10  Pulmonary
11  Spinal cord injury
12  Stroke
13  Other (specify)

Are you involved in rehabilitation nursing research activities?
  Yes    No

Are you a member of the American Nurses Association (ANA) or state nurses’ association?
  Yes   No

Your age range
1  20-24
2  25-29
3  30-34
4  35-39
5  40-44
6  45-49
7  50-54
8  55-59
9  60+

Racial-ethnic origin (optional)
1  Caucasian
2  African American
3  Hispanic
4  Native American
5  Asian
6  Other

Gender
1  Male 2  Female

Please indicate which 2 special interest groups you would like to join:
1  Administrative/management
2  Admissions liaison
3  Advanced practice nurses
4  Educators
5  Case management/insurance/consulting
6  Staff nurses
7  Gerontology
8  Home health care
9  Pain
10  Pediatrics
11  Researchers
12  Subacute care

Note: Occasionally, ARN sells its membership list to agencies and companies whose products or services may be of interest to rehabilitation nurses. The ARN membership directory is also available for purchase. Please indicate if you do not wish to have your name sold or provided as part of ARN's mailing list and/or directory.

   I do not want my name sold or provided as part of ARN’s mailing list.

  I do not want my name printed in the ARN membership directory.

Please accept my application to join the following category:

  Voting member (RN) .................................. $110.00
This membership is available to registered nurses concerned with or involved in the practice of rehabilitation nursing.

  Non-voting member ................................... $110.00
This type of membership is available to members of other healthcare disciplines and other interested individuals. Nonvoting members receive all member benefits but may not vote or hold office.

  Corporate or facility member ........................ $2000.00
These are special nonvoting memberships open to companies and facilities that support the goals and mission of ARN. These members receive preferential exhibit booth placement and special recognition at the ARN conference. In addition, they are listed in ARN's membership directory; ARN's journal, Rehabilitation Nursing; and the newsletter, ARN Network, and they receive a member plaque. Membership is extended to a single organizational designee who receives one full registration for the ARN conference, a subscription to Rehabilitation Nursing and ARN Network, and reduced fees on ARN mailing labels, programs, and products.

* Chapter Dues :  Listing of Local Chapters

Chapter Name : 

TOTAL : 

* ARN membership is required for chapter membership

Method of payment:   Check
(Make check payable in U.S. funds only to ARN. A charge of $25 will apply to checks returned for insufficient funds.)

   VISA   Master Card   American Express
(If rebilling of a credit card is necessary, a $25 processing fee will be charged.)

Account Number 

Exp date 

Signature 

Association of Rehabilitation Nurses
4700 W Lake Ave
Glenview, IL 60025
800/229-7530
info@rehabnurse.org