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Registration is fast and easy online at ksnurses.com!
2 0 1 5 K S N A A N N UA L M E M B E R S H I P A S S E M B LY
“Quality Care, Ethical Practice”
Friday-Saturday, October 2-3
Wichita Marriott, 9100 Corporate Hills Drive (Kellogg and Webb Roads)
(Discounted Hotel Rooms $105/night; call 1-800-228-9290 (by 5 p.m., September 11)
First Name Last Name
Credentials License # (for CNEs)
Home Address
City, State, Zip
Daytime Phone
Email
KSNA Member (circle): Yes
No
If yes, indicate your KSNA District #
Special Dietary Requirements (please indicate type)
If an undergraduate student, name of school _____________________________________________________________
Continuing Nursing Education (CNE) contact hours will be awarded for 100% attendance at all sessions in accordance with your registration preference.
Your license # and signature are required at the registration check-in table and your completed evaluation form. Certificates will be sent to you within 10
days after the Membership Assembly.
Register by September 20 and receive a special discount on the price!
Fees by member type for both
days, Friday and Saturday,
October 2 & 3
Full Event
Fees
(after Sept. 20)
Friday Only
10/02/2015
(after Sept. 20)
Saturday Only
10/03/2015
(after Sept 20)
RN but NOT a KSNA Member
$295 ($320)
$160 ($185)
$160 ($185)
$
Current/Active KSNA Member
$150 ($175)
$100 ($125)
$100 ($125)
$
KSNA State Officer/Board Member
$75 ($100)
NA
NA
$
KSNA Member 65 yrs and older
$75 ($100)
$100 ($125)
$100 ($125)
$
Undergraduate Student Nurse
$40
$25
$25
$
$20 each
___ x $20
Attend Individual CNE Session(s) Only
Optional KNF Event
(Friday 10/02/2015 6:30-9:00 pm)
Dinner &
Silent Auction
Total Due to KSNA
(add column)
___ x $20
No. Persons____ x $25.00 each
$
T O TA L D U E T O K S N A $
Are you a District President or your District President’s designee, appointed to attend the District President’s
Breakfast as representative for your KSNA District on Friday, 10/02/2015, at 7:30 a.m.? If yes, check below.
___District Presidents’ Breakfast (DPs only or their designee), 7:30-8:30 am, NO ADDITIONAL FEE
PAYMENT: ___Check/Money Order (payable to KSNA)
___Visa ___MasterCard ___Discover Card ___Diners Club (secured processing
16-digit Card # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiration _ _ / _ _ _ _ 3-Digit Security Code _ _ _
Cardholder’s Name (if different from registrant)_____________________________________________
Signature of Cardholder_______________________________________________________________
Return to KSNA, 1109 SW Topeka Blvd., Topeka, KS 66612-1602; email: [email protected] or FAX 785-233-5222