EN Delegate Application

Before you may submit your application, please review these important documents below:

Delegate Agreement
File Size:	89 kb
File Type:	pdf

Download File

If selected, this agreement outlines your responsibilities and duties as a delegate. Submitting your application serves as an electronic signature to this form.

Expense Reimbursement Form
File Size:	16 kb
File Type:	xlsx

Download File

This reimbursement form must be completed and sent to the SD ENA Treasurer within 30 days of your return. Submitting your application serves as an agreement to these terms.

EN Delegate Application

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Years ENA Member *

Previous Delegate Year (if applicable) *

Educational Programs (specify year)

will be verified with registry

CEN *

CFRN *

TNCC Instructor *

CPEN *

ENPC Instructor *

TCRN *

SD ENA Board Member (current or past)

Committee Chair Person (current or past 12 months)

List Committee(s) both state and national. Please provide a description of activities. *

Committee Member (current or past 12 months)

List committee(s) both state and national. Please describe activities. *

Meeting Attendance (since previous general assembly)

Please discuss your meeting attendance for state and national meetings *

Other Activities

Please discuss your involvement with other activities (examples include: publishing an article on emergency nursing, community service, nursing research, and injury prevention activities) *

Narrative

Why do you want to be a delegate? *

I agree to the above delegate responsibility form. *

I agree to the above reimbursement form and policy *

Submit