Nurse Think Tank Interest form
Activism and the Art of Nursing - July 13-14, Augusta, GA.
Information collected here will never be sold. This information is being collected to solicit interest and coordinate logistics.
* Required
What is your name?
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Your answer
What is your email address?
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Your answer
What is your cell phone number?
Your answer
Tell us about you!
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Your answer
Tell us about why you are interested in participating in our Nurse Activism Think Tank.
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Your answer
Do you have special talents you'd like to share?
Your answer
What region are you from?
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Choose
Southeast
Midatlantic
New England
Midwest/Central
Pacific Northwest
West Coast
Outside the US
If you chose "Outside the US" for your last response, where are you coming from?
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Your answer
How definite is your attendance?
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I'm hoping to attend but seems unlikely
1
2
3
4
5
I AM THERE!
How will you arrive?
Air
Land
Sea
Clear selection
Willing to carpool and/or share accommodations?
Yes
No
Can we share your responses to facilitate organization?
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Yes
No
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