FLORIDA NEONATAL PEDIATRIC NETWORK ASSOCIATION INC.

2003-2004 MEMBERSHIP

 

THE FLORIDA/NEONATAL/PEDIATRIC

TRANSPORT NETWORK ASSOCIATION IS

DIRECTED TOWARD ANY HEALTH CARE PROFESSIONAL OR PROVIDER INCLUDING, PHYSICIANS, NURSES, PARAMEDICS and EMT's

WHO ARE INVOLVED IN NEONATAL/PEDIATRIC TRANSPORT.

 

Memberships include newsletter, meeting notices, legislative updates, and additional    educational opportunities for the networking and growth in the association.

ANNUAL DUES: __________$10.00 PERSONAL MEMBERSHIP DUES

                   __________$100.00 ORGANIZATIONAL DUES

                                 (INCLUDES ONE VOTING MEMBER)

                   __________$150.00 CORPORATE MEMBERSHIP DUES

                  NAME/TITLE :___________________________________________

FOR ORGANIZATION, PLEASE INDICATE VOTING MEMBER

INSTITUTION/ORGANIZATION:_________________________________________

ADDRESS:_____________________________________________________________

CITY/STATE/ZIP:______________________________________________________

PHONE: ________________FAX:_______________E-MAIL:___________________

PLEASE COMPLETE THE FOLLOWING STATISTICAL DATA FOR OUR RECORDS:

Type of transports your program does:

___Neonatal ___Pediatric ___ Adult ________Other

Name of Program Director:_________________________________________

Name of Medical Director:__________________________________________

Mode of transport: ____Ground ___Helicopter ____Fixed Wing

Please check if any of the following are done on transport:

              ___ECMO ____Jet Ventilation _____ Nitric Oxide

 

Please return completed application form with accompanying check to:

Florida Neonatal/ Pediatric Transport Network Assoc. (FNPTNA)

Nancy Burke

c/o South Miami Hospital - NICU

6200 S.W. 73 Street

Miami, FL 33143