General

General Membership Payment

Be sure to enter your BILLING address.

TERMS:
– $75 / year payable via Credit Card.
– Credit Card payments utilize a system of automatic billing for renewals.

First Name:* First Name Required

Last Name:* Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phone:* Phone is Required

Nursing Credential:* Nursing Credential is Required

Parish Name:* Parish Name is Required

Diocese:* Diocese is Required

Employer: Employer is not valid

Position: Position is not valid

Are You Retired:* Are You Retired is Required

No Yes

Student Membership: Name of School Attending: Student Membership: Name of School Attending is not valid

Student Membership: Personal (not school) Email Address: Student Membership: Personal (not school) Email Address is not valid

Name of Local Council: Name of Local Council is not valid

Referred By: Referred By is not valid

As a benefit of my membership, I understand that my contact information will be shared with the local Regional Director to promote networking.: As a benefit of my membership, I understand that my contact information will be shared with the local Regional Director to promote networking. is not valid

Yes

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Password Strength

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