UTAH ENA GENERAL ASSEMBLY DELEGATE APPLICATION

Name: * ENA Membership# * Address: * Phone: --* City: * Zip Code: *

* Indicated required fields

You must have been an ENA member for at least one year and remain a member through 2010

A specific number of points have been assigned to the following activities for the purpose of selecting delegates to the General Assembly. Please tally and list your total points in the appropriate space on the application. Indicate how you meet the qualifications adjacent to each activity.

ACTIVITY DESCRIBE PARTICIPATION POINTS Officer: State / Chapter 20pts Officer: State / Local Committee Chair 15pts State / Local Committee Work Participation 10pts=75%-100% 5pts=50%-74% 2pts=<50% State Council Meeting Attendance (last 12 months) Participation 10pts each Current CEN, TNCC, ENPC, CATN Provider Participation 10pts each Current TNCC, ENPC, CATN or ENCare Instructor Participation 10pts each Other teaching activities Participation 10pts each Published emergency nursing articles 10pts Attended national /state /local ENA sponsored meetings /activities (last 12 months) 10pts Projects (public education, legislative involvement, safety fairs, etc.) 5pts

TOTAL:

List teaching activities, other than ENPC, TNCC, or EN CARE, that you’ve done for emergency nurses or EMS personnel. Classes that are taught as part of your job requirement should not be counted.

All applications will be reviewed by the Utah ENA State Council to determine which qualified nurses have accumulated the highest number of points. Qualified individuals with the highest point total shall fill the allotted number of delegate positions. Alternate delegates may also be selected, based on point totals. Delegates will be reimbursed for coach airfare, Scientific Assembly tuition, and 1/2 of the amount for three nights hotel based on double occupancy. Delegates are required to attend all delegate sessions and each session of the General Assembly. Delegates must provide receipts for all expenses.