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PROFESSIONAL INFORMATION

Information below is needed for both conference registrants and membership applicants.

NATIONAL PROVIDER IDENTIFIER (NPI)#______________________

Student Post-Master’s StudentName of School: _________________________________________________________________________

City: ______________________State: ____________ Program Specialty: __________________________

Anticipated Year of NP Program Completion: ___ ___ ___ ___

If applicant is a student in an entry level NP program, skip Professional Information section and go to Membership Dues Information section below.

STUDENT MEMBERSHIP INFORMATION

(Utilizing federal classifications for ethnicity and race. Check all that apply.)

Gender: Female   Male Year of Birth: 19 ___ ___Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White

DEMOGRAPHIC INFORMATION

New Member Renewal/Former - Member # _________________________________Name:______________________________________________________________________________________ First Middle LastPreferred Mailing Address: Home Work

______________________________________________________________________________________ Company Name (If this is your work address.)______________________________________________________________________________________ Street______________________________________________________________________________________ City State Zip Code

Home Phone:

Work Phone:

Cell Phone:

email:AANP policy allows for the release of members' mailing address for educational, research and recruitment purposes only.

Check box if you do not want your mailing address released.Phone and email information is for internal use only by AANP staff, elected officials, state representatives and AANP vendors for fulfilling member services.

Ext.

2019 AANP NATIONAL CONFERENCE REGISTRATION & MEMBERSHIP APPLICATION

MEMBERSHIP DUES INFORMATION

MEMBERSHIP TYPE: Student $55 Post-Master’s $95 Career Starter $95 NP $135 Associate $145 Retired $55For additional membership information and to join or renew your membership, visit aanp.org. Memberships are non-refundable.

SPECIALTY PRACTICE GROUPS (SPGs) :SPGs are communities within AANP for those who share a common interest in advancing knowledge and learning in select specialty areas. The community sites support discussions, document sharing, collaboration and networking. Each SPG is $20 annually. SPG Membership Type: 

Acute Care Cardiology Convenient/Urgent Care Dermatology Emergency Endocrine Entrepreneur Gastroenterology Health Informatics/Telehealth

Have you ever served on active duty in the U.S. Armed Forces, Reserves or National Guard?

Never served in the military Only on active duty for training in the Reserves or National Guard

Currently on active duty On active duty in the past, but not presently

MILITARY INFORMATION

Assisted Living College Health Community Health Center Correctional/Prison Facility Emergency Room/Urgent Care Family Planning Clinic Federally Qualified Health Center Government Agency Health Department HMO Home Health Care Hospice/Palliative Care Hospital Inpatient Clinic Hospital Outpatient Clinic Indian Health Service Insurance Company, private Insurance Company, public Long-term Care Facility

Migrant Health Clinic Military/DoD Occupational Health Clinic Private Group Practice Private NP Practice Private Physician Practice Psych/Mental Health Facility Public Housing Primary Care School Health Clinic Rehabilitation Facility Retail Clinic Rural Health Clinic University, private University, public Urgent Care VA Facility Other, please specify:

NP WORK SETTING: (Please select ONE setting, preferably your main work site.)

ARE YOU LICENSED AS AN NP?    Yes   NoARE YOU CERTIFIED AS AN NP?    Yes   No

NP CERTIFICATION(S): (Please check all that apply.) Acute Care Adult Adult-Gerontology-Acute Care Adult-Gerontology-Primary Care Dermatology Diabetes Management – Advanced Emergency Family Gerontology Hospice and Palliative Care Neonatal Oncology

Orthopedics Pediatrics-Acute Care Pediatrics-Primary Care Pediatrics-Primary Care Mental

Health Psychiatric-Mental Health Psychiatric-Mental Health-Adult Psychiatric-Mental Health-Family School Health Women's Health None Other, please specify:

YOUR CLINICAL FOCUS AT YOUR MAIN NP WORK SITE: (Please select ONE clinical focus.)

Administration Cardiology Complementary/Alternative Dermatology Emergency Endocrinology End-of-life Care ENT Faculty Gastroenterology Genetics Health Promotion Hematology Immunology/Rheumatology Neurology

OB/GYN Occupational Oncology Orthopedics Pain Medicine Primary Care Psychiatric Research Respiratory Surgical Urgent Care Urology/Nephrology Wound Care None Other, please specify:

ARE YOU WORKING OR VOLUNTEERING AS AN NP?  Yes No, I am an NP, but I am not currently working No, I am a retired NP No, I am an NP student

No, I am another APRN (CNS, CNM, CRNA) No, I am another type of nurse No, I am not an NP or a nurse

EDUCATIONAL INFORMATION

Highest Level of Education: (Please select ONE.) Certificate Nursing Associate's Non-nursing Associate's Nursing Bachelor's

Non-nursing Bachelor's Nursing Master's Non-nursing Master's DNP

Nursing PhD Other Nursing Doctorate Non-nursing Doctorate

Year of NP Program Completion: (If you hold degrees from multiple NP programs, enter the year that you completed your initial program.)___ ___ ___ ___

To register by mail or fax please complete this form, print and mail to:  AANP, P.O. Box 12846, Austin, TX 78711 or fax to 512-442-6469

International Neurology Obesity Occupation/Environment Health Orthopedics Pain Management Psych and Mental Health Pulmonary/Sleep

TUESDAY, JUNE 18, 2019 1ST CHOICE 2ND CHOICE 3RD CHOICE

WORKSHOPS / SPECIALIZED SEMINARS 7:45 a.m.–12 p.m. ______________________ ______________________ ______________________1–5 p.m. ______________________ ______________________ ______________________RAPID FIRE PRESENTATIONS4–4:20 p.m. ______________________ ______________________ ______________________4:30–4:50 p.m. ______________________ ______________________ ______________________5–5:20 p.m. ______________________ ______________________ ______________________5:30–5:50 p.m. ______________________ ______________________ ______________________6–8 p.m. Welcome Reception at the Indianapolis Zoo ______________________

WEDNESDAY, JUNE 19, 2019 1ST CHOICE 2ND CHOICE 3RD CHOICE

WORKSHOPS / SEMINARS7:30–11:30 a.m. ______________________ ______________________ ______________________7:30 a.m.–1 p.m. FCCS - Group 1 ______________________7:30 a.m.–1 p.m. FCCS - Group 2 ______________________CONCURRENT PRESENTATIONS7:30–8:30 a.m. ______________________ ______________________ ______________________8:45–9:45 a.m. ______________________ ______________________ ______________________SPECIALTY PRACTICE GROUPS /INTEREST FORUM10–11 a.m. ______ ________________ ______________________ ______________________MILITARY / UNIFORMED SERVICES10:45 a.m.–1:45 p.m. (Open to Active, Retired Military & USPHS Attendees ONLY) ______________________RAPID FIRE PRESENTATIONS11:15–11:35 a.m. ______________________ ______________________ ______________________1:15–1:35 p.m. ______________________ ______________________ ______________________GENERAL SESSION - OPENING KEYNOTE2–4 p.m. ______________________REGIONAL MEETINGS4:15–5:15 p.m. ______________________ ______________________ ______________________CONCURRENT PRESENTATIONS4:15–5:15 p.m. ______________________ ______________________ ______________________MILITARY / UNIFORMED SERVICES5:30–7 p.m. ______________________ ______________________ ______________________

THURSDAY, JUNE 20, 2019 1ST CHOICE 2ND CHOICE 3RD CHOICE

WORKSHOPS / SEMINARS8 a.m.–12 p.m. ______________________ ______________________ ______________________CONCURRENT PRESENTATIONS8–9 a.m. ______________________ ______________________ ______________________9:15–10:15 a.m. ______________________ ______________________ ______________________10:30–11:30 a.m. ______________________ ______________________ ______________________INTEREST FORUMS10:30–11:30 a.m. ______________________ ______________________ ______________________

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Name: First Middle Last

Please write in the entire session number (i.e., 19.1.001) for your preferred selections. Where applicable, indicate your first, second and third choice. No selection is guaranteed. If no selections are provided, conference staff will place you in General Sessions only.

Please Note: You may register for only one session per timeframe.

To view all sessions and current availability, register online at indy.aanp.org.

CONFERENCE SESSIONS

FRIDAY, JUNE 21, 2019 1ST CHOICE 2ND CHOICE 3RD CHOICE

GENERAL SESSION - CLOSING KEYNOTE8–8:45 a.m. ______________________WORKSHOPS / SPECIALIZED SEMINARS 9 a.m.–12 p.m. ______________________ ______________________ ______________________CONCURRENT PRESENTATIONS9–10 a.m. ______________________ ______________________ ______________________10:15–11:15 a.m. ______________________ ______________________ ______________________RAPID FIRE PRESENTATIONS11:25–11:45 a.m. ______________________ ______________________ ______________________ATTENDED NP POSTERS – GROUP 21:30–3:15 p.m. ______________________CONCURRENT PRESENTATIONS3:30–4:30 p.m. ______________________ ______________________ ______________________

SATURDAY, JUNE 22, 2019 1ST CHOICE 2ND CHOICE 3RD CHOICE

WORKSHOPS / SEMINARS8–11 a.m. ______________________ ______________________ ______________________CONCURRENT PRESENTATIONS8–9 a.m. ______________________ ______________________ ______________________9:15–10:15 a.m. ______________________ ______________________ ______________________ATTENDED NP POSTERS – GROUP 310:30–11:45 a.m. ______________________CONCURRENT PRESENTATIONS1:15–2:15 p.m. ______________________ ______________________ ______________________2:30–3:30 p.m. ______________________ ______________________ ______________________GENERAL SESSION - CLOSING KEYNOTE3:45–4:45 p.m. ______________________

SUNDAY, JUNE 23, 2019 1ST CHOICE 2ND CHOICE 3RD CHOICE

WORKSHOPS/SPECIALIZED SEMINARS8– 11 a.m. ______________________ ______________________ ______________________CONCURRENT PRESENTATIONS8–9 a.m. ______________________ ______________________ ______________________9:15–10:15 a.m. ______________________ ______________________ ______________________10:30–11:30 a.m. ______________________ ______________________ ______________________

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Name: First Middle Last

Please write in the entire session number (i.e., 19.1.001) for your preferred selections. Where applicable, indicate your first, second and third choice. No selection is guaranteed. If no selections are provided, conference staff will place you in General Sessions only.

Please Note: You may register for only one session per timeframe.

To view all sessions and current availability, register online at indy.aanp.org.

CONFERENCE SESSIONS

THURSDAY, JUNE 20, 2019 CONT. 1ST CHOICE 2ND CHOICE 3RD CHOICE

ATTENDED NP POSTERS – GROUP 13–4:45 p.m. ______________________RAPID FIRE PRESENTATIONS5–5:20 p.m. ______________________ ______________________ ______________________5:30–5:50 p.m. ______________________ ______________________ ______________________

Received by 5/6/1911:59 p.m. CT

Received after 5/6/1911:59 p.m. CT

NOTE:

IF YOU REGISTERED ABOVE FOR THE ENTIRE CONFERENCE, SKIP THE ONE DAY REGISTRATION FEES CATEGORY.

NOTE:

IF YOU ONLY REGISTER FOR A WORKSHOP ON EITHER TUESDAY, 6/18 OR SUNDAY, 6/23 YOU WILL ALSO BE CHARGED A ONE-DAY REGISTRATION FEE.

Subtotal Registration Fee:

Subtotal One Day Fee:

Forward registration form & payment to: a.m.ERICAN ASSOCIATION OF NURSE PRACTITIONERS • P.O. BOX 12846 • AUSTIN, TX 78711If paying by credit card you may fax to AANP at 512-442-6469.

Enclosed is my check payable to: American Association of Nurse Practitioners Please charge to my credit card: Visa MasterCard American Express

Card Number: ___________________________________________________________ Expiration Date: ___________________ Billing Zip Code: ____________________ Security Code ______________

Cardholder Name: _____________________________________________________________________________ Signature: ___________________________________________________________Please Print

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By submitting this registration, registrant acknowledges they have read and agree to the Terms of Service and Release of Liability published online at release.aanp.org.

CONFERENCE FEES

Non-members are invited to join now and attend at member rates!

June 18 – 23, 2019 Registration Fees(Please Select Your Registration Category)

NP Member $595 $645Associate Member $595 $645Student Member $195 $245Post Master’s Student Member $515 $565Career Starter Member $370 $420Retired Member $370 $420Non-Member $740 $790

One Day Registration Fees(One-day Registrants: Please Indicate the Day You Are Attending.)

Tues. 6/18   Wed. 6/19   Thur. 6/20   Fri. 6/21   Sat. 6/22  Sun. 6/23(Please Select Your Registration Category)

NP Member $360 $410Associate Member $360 $410Student Member $195 $245Post Master’s Student Member $320 $370Career Starter Member $245 $295Retired Member $245 $295Non-Member $425 $475

Acute Abdomen (19.5.011) Advanced Suturing (19.5.012) Aromatherapy (19.1.012; 19.1.042) ASa.m. Treatment of Opioid Use Disorder: 2 Parts

(19.1.007; 19.1.057) Bedside Ultrasound (19.1.024; 19.1.054) Basic Suturing (19.3.020; 19.6.010) Commercial Motor Vehicle (CMV) License Workshop

2 Parts (19.1.019; 19.1.045) Diabetes: Using Injectables & Technology (19.1.010; 19.1.040) Emergency HEENT Procedures (19.1.028; 19.1.058; 19.2.020) Extremity Fractures: Basic Splinting (19.1.011; 19.1.041) FCCS Course: Group 1 or Group 2 (19.2.026; 19.2.027)

Honing Your Cardiac Exam (19.1.013; 19.1.043) Hypnosis (19.1.029; 19.1.059) Lower Extremity Issues (19.5.014) Minor Surgical Skills (19.5.013; 19.6.011) Musculoskeletal Injections

(19.1.030; 19.1.060; 19.2.021; 19.3.032) Neurological Exam Essentials (19.6.012) Office Gynecology Procedures (19.1.031; 19.1.061) Performing Thoracic Procedures (19.1.009; 19.1.039) Punch and Shave Biopsies (19.4.028) Upper Extremity Issues (19.4.029) Urgent Care Procedure Skills (19.1.008; 19.1.038)

Women’s Sexual Health: 2 Parts (19.1.018; 19.1.048)

Acute Care Cardiology Convenient/Urgent Care Dermatology Emergency Endocrine Entrepreneur Gastroenterology Health Informatics/Telehealth

To register for conference, please remember to mail or fax pages 1R– 4R. Payment must be included with form. Thank you!

AANP Membership Fees(Please Select Your Membership Category)

NP Member $135 Student Member $55 Associate Member $145 Post Master’s Student Member $ 95 Retired Member $55 Career Starter Member $ 95

Specialty Practice Group (SPG) Membership Fees Each SPG is $20 annually.

Workshops/Specialized Seminars/Seminar Fees(Please Select Your Workshops)

Subtotal Workshop and Seminar Fees:

Grand Total:

Subtotal SPG Fees:

Subtotal Membership Fee:

Name:First Middle Last

International Neurology Obesity Occupation/Environment Health Orthopedics Pain Management Psych and Mental Health Pulmonary/Sleep

$125$125$125$125

$125$125$125

$125$125$125$200

$125$125$125$125$125

$125$125$125$125$125$125$125