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Registration of Chapter or Local / Regional Club (* Required)
Nursing Club / Organization:	*
School / College / University:
*not affiliated with a school / college / unversity*
Mailing Address:	*
City:	*
State/Province:	*
Zip/Postal Code:	*
Person Requesting Registration
Name:	*
E-mail Address:	*
Phone:	*
Dean / Director of Nursing
Name:	*
E-mail Address:	*
Phone:	*
President of Club / Organization
Name:	*
E-mail Address:	*
Phone:	*
Treasurer of Club / Organization
Name:	*
E-mail Address:	*
Phone:	*
Purpose of Fundraising