Regional Status Profile

* Indicates a Required Field

Year:*

Region:*

Coordinator

Name:*

Credentials:*

Address:*

City:*

State:*

Zip Code:*

Phone:*

Email Address:* (do not use work email)

Employment Title:*

ENA Membership Number:*

Representative #1

Name:*

ENA Membership Number:*

Phone:*

Email Address:* (do not use work email)

Representative #2

Name:*

ENA Membership Number:*

Phone:*

Email Address:* (do not use work email)

Alternate #1 (optional)

Name:

ENA Membership Number:

Phone:

Email Address: (do not use work email)

Alternate #2 (optional)

Name:

ENA Membership Number:

Phone:

Email Address: (do not use work email)

Alternate #3 (optional)

Name:

ENA Membership Number:

Phone:

Email Address: (do not use work email)

Alternate #4 (optional)

Name:

ENA Membership Number:

Phone:

Email Address: (do not use work email)

Requests for financial support from the state must be submitted by the regional coordinator or co-signed/approved if course application.

Regions MUST NOT MAINTAIN ANY SEPARATE FINANCIAL ACCOUNTS. This would violate NYS Not For Profit Laws.

The coordinator must assure regional representation at 75% of the yearly state meetings either virtual or in person. IF a region is not meeting this requirement, the Board of Directors will contact the coordinator and if necessary dissolve/merge the region.

Address

Phone Number

Email Us