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ARN National Membership Application

Note: You must become a member of the national organization in order to become a member of the local chapter. Use this form for both.

Richt-click here and choose "Save Target As" to download the Microsoft Word document to your PC.

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: ___ Business ___ Home
(Check one box to indicate where you prefer to receive your mail.)

Address _____________________________________________

City ____________________ State _____ Zip _________

Preferred Telephone: ___ Business ___ Home

Phone __________________________________________

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 : ____$25_______ 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 _________________________________________

Monthly deduction option:

Complete the following only if you wish to have your membership and chapter dues deducted from your checking account monthly.

I hereby authorize the Association of Rehabilitation Nurses, hereinafter called ARN, to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my (our) account at the depository named below to debit and/or credit the same to such account for (please check one):

____ ARN dues only ____ ARN and chapter dues

This authorization is to remain in full force and effect until ARN has received written notification from me (or either of us) of its termination in such time and in such manner as to afford ARN and the depository a reasonable opportunity to act on it.

Date ______________

Name of Bank ______________________________________

Signature _________________________________________

Signature of Spouse (For joint checking accounts only)

_______________________________________________

Take one check from your checkbook and write the word “VOID” across it in large letters. (We regret we can accept only checks issued by U.S. banks.) ARN will use the information on the check to initiate automatic monthly withdrawals from this account. Your checking account statement will reference ARN as the payee.

Mail this application and your voided check to:
Association of Rehabilitation Nurses
PO Box 3781
Oak Brook,IL 60522

Membership dues are not deductible as a charitable contribution. Membership dues may be deductible as an ordinary and necessary business expense. Consult your tax adviser for information.