This contact information may be used by MNA for routine emergency preparedness communications and/or in the event of an emergency or disaster. The information may be shared with emergency relief agencies or organizations. You will periodically be asked by the MNA to update your data to keep contact information current.

PLEASE NOTE: MNA strongly encourages nurses to obtain personal professional liability coverage!

First name:

          MI:

Last name:

Please indicate:

RN:   NP:

Street address:

City:

State:

Zip code:

Daytime phone:

Evening phone:

Mobile number:

Email address:

Please note: While your e-mail address is not mandatory, we recommend that you supply it, as this is our preferred form of communication with our volunteers.

Other information or skills
(i.e. languages spoken, etc):