Nurses Lead - Self-Nomination Form
Please complete this self-nomination form to be considered to participate in the Rhode Island Action Coalition's (RIAC) Nurses Lead, Nurse Leadership Development Program. The program will offer Registered Nurses the opportunity to develop the fundamental knowledge and skills necessary to be an active Board participant. Following the seminar, participants will be matched with a nurse leader mentor to coach them as they seek their first board position. The program fee ($100) includes CEUs and lunch for the full-day seminar on April 28th. Applicants that may apply for a fee waiver by emailing info@riactioncoalition.org.

Note: this form is only accessible via Google Chrome or Mozilla Firefox internet browsers. Please contact the below email if you have connectivity issues.

For questions email info@riactioncoalition.org.

First Name *
Your answer
Last Name *
Your answer
Credentials *
Your answer
Mailing Street Address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Preferred Phone Contact *
Your answer
Preferred Email Contact *
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Rhode Island Action Coalition.