2007 Delegate Form for the 54th AORN Congress Orlando,

Document Sample
2007 Delegate Form for the 54th AORN Congress Orlando, Powered By Docstoc
					     2009 Delegate Form for the 56th AORN Congress Chicago, IL
                           Deadline for Submission is February 13, 2009*

I am willing to serve Mass Chapter 1 as a    Delegate or     Alternate Delegate at the 2009 Congress.
My AORN Membership expires on:            (required)
Email address:
Is this your first Congress?          Yes          No
Please Print:
Name:
Home address:
City, State, Zip:
Home phone:                  Work phone:
Employer:
Manager’s Name:
Employer/Manager’s mailing address:
Hospital address:
The following is the point system for Chapter Delegates/Alternate Delegates.

           ACTIVITY                           ADDITIONAL INFO                 POINTS   POINTS
                                                                              ASSIGNED EARNED
Office of Chapter                  List:                                      5

Chair Committee/Task Force         List:                                      4 each

Member Committee/Task Force        List:                                      2 each

Immediate Past President                                                      2
Monthly AORN Meetings              Check all that apply:     May 08           1 each
Attended                           Nov 08        Jan 09       Feb 09

Workshop Attendance                Check all that apply: Spring08             2 Each
                                                         Fall 09
CNOR                                                                          4
CRNFA                                                                         4
Recruited New Member(s)            Name(s):                                   1 each
Presenting Program/Speaker at      List:                                      4 each
AORN Chapter or National
National Committee and/or          List:                                      2 each
Officer
Writing for Newsletter/            Submit Copy if possible                    2 each
Publishing Article
Monitor/Teller/Congress                                                       2 each
Involvement
   TOTAL POINTS EARNED             YOU MUST SUBMIT THE POINTS
                                   TO BE CONSIDERED!
POINTS ARE ACCUMULATED IN THE CALENDAR YEAR BEFORE CONGRESS. POINTS ARE
SUBJECT TO VERIFICATION BY THE CONGRESS COMMITTEE.
Please return completed form in person, postal mail or email to:
                    Debra Savage
                    51 Presentation Rd #2
                    Brighton, Ma 02135
debbiesavage@comcast.net