Today's Date

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HNA Member ID

First Name

Last Name

Street Address

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Place of employment (optional)

How long have you been working in the nursing field? (If applicable) How long have you been working in the nursing field? (If applicable) Less than 1 year 1-3 years 4-8 years 9-15 years More than 15 years

Dietary restrictions Dietary restrictions No Dietary Restrictions Vegetarian I do not plan to have Breakfast or Lunch at the Conference.

Do you have any special accommodations? Do you have any special accommodations? No Yes

Do you have any special accommodations? If yes, please explain.

*I hereby grant permission to Hmong Nurses Association to take photos and video with sound recording of me on August 3, 2024 and August 4, 2024 at Sacramento State, and to use the photographic or electronic reproduction of me in publications, news releases, online platforms including Hmong Nurses Association’s Facebook page and website, and in other communications and public relations outlets as it is applicable to the mission of Hmong Nurses Association. *I hereby grant permission to Hmong Nurses Association to take photos and video with sound recording of me on August 3, 2024 and August 4, 2024 at Sacramento State, and to use the photographic or electronic reproduction of me in publications, news releases, online platforms including Hmong Nurses Association’s Facebook page and website, and in other communications and public relations outlets as it is applicable to the mission of Hmong Nurses Association. Yes, I agree No, I disagree

Any concerns or questions? (Optional)