2021 Practising Membership: RN/GN - online donation form
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INTERNAL USE ONLY
Entered in iMIS
Confirmation email sent
Signed up for Pre-Auth
Entered Pre-Auth info
iMIS ID: _____________
2021 Practising Membership: RN/GN
For new applicants or renewing members * Bolded consents are required
*I certify that I am registered or applying to register as a practising nurse with the College of
Registered Nurses of Manitoba and my registration is not currently cancelled
Personal Information
_____________________
Registration/ID Number
_________________________________ ___________ __________________________________
First Name Middle Initial Last name
You do not need to complete the following fields if you are currently a member and none of the
information has changed.
__________________________________________________________________________________
Address
___________________________ _________________________ ___________________________
City Province Postal Code
___________________________ _____________________________________________________
Country Email Address
Home/Mobile/Work Phone Number: ____________________________________________________
(Please circle the phone number type)
_____/_____/__________ Prefer Renewal Notice by mail? Yes No
Birth Date (MM/DD/YYYY)Professional Information
________________________________________ ________________________________________
Years of Practice Primary Role
________________________________________ ________________________________________
Practice Area Region
*I certify that the information provided is true. I understand that it is my responsibility to notify
the Association of a change of name or address and that email will be the primary method of
communication.
Specialty Groups
The Association encourages members to consider exploring membership in one of the specialty
groups. These organizations are closely linked with their national organizations and provide nurses an
opportunity to enhance their specialized nursing knowledge and skills, while building valuable
connections with professional colleagues.
Please indicate below the nursing specialty groups you are interested in receiving more information
from. By checking the box, you give us permission to share your name and email with the group.
Canadian Association of Critical Care Nurses Infection Prevention and Control Canada
(CACCN) MB Chapter (IPAC) MB Chapter
Canadian Association of Nurses in Oncology Manitoba Association of Perianesthesia
(CANO) MB Chapter Nurses
Canadian Association of Pediatric Nurses Manitoba Gerontological Nurses Association
(CAPN) Manitoba Operating Room Nurses
Canadian Vascular Access Association (CVAA) Association (MORNA)
MB Chapter Manitoba Primary Care Nurses Association
Clinical Nurse Specialist Group Manitoba Renal Program
Community Health Nurses of Manitoba Nurse Practitioner Association of Manitoba
Emergency Department Nurses Association Canadian Council of Cardiovascular Nurses
of Manitoba (EDNA) (CCCN) MB Chapter
Indigenous Nurses Association of MB Inc. Harm Reduction Nurses Association MB
Manitoba Occupational Health Nurses Chapter
Interest Group (MOHNIG)
Professional Development Interests
Please indicate your top three professional development interests to help guide us in our planning.
Please select one Please select one Please select one
___________________________ __________________________ __________________________
Area of Interest One Area of Interest Two Area of Interest Three
2Consents
Privacy
The Association values and respects your privacy. We are also committed to enabling you to access all
the member benefits you are entitled to through your membership. The Association has developed
a Privacy Policy to demonstrate our accountability and commitment through a transparent policy
regarding the collection, use and sharing of personal information.
*I have read and agree with the terms of the Privacy Policy regarding the collection, use,
disclosure and destruction of my personal information.
Canadian Nurses Association
As stated in the Association’s privacy policy, personal information is collected for the purpose of
providing you access to member benefits in the Canadian Nurses Association (CNA) including the
Canadian Nurse Journal, online resources like NurseOne and other member benefits and services. In
addition to receiving your name, address and registration number and email address (to receive
member benefits), CNA needs your consent to send you electronic communications like “CNA Now”.
Please add me to/keep me on CNA’s email contact list, so I can receive information and
newsletters from CNA and can be kept up-to-date on new products, promotions, services, reports
and other CNA activities.
I understand I may remove my consent at any time by selecting the UNSUBSCRIBE feature that
accompanies the communication or by contacting CNA directly at 50 Driveway, Ottawa ON K2P
1E2. Phone 613-237-2133 or 1-800-361-8404.
Canadian Nurses Protective Society
As stated in its privacy policy, the Association also collects your information for the purpose of
providing you access to professional liability protection. As a member of the Association, you are
eligible for Canadian Nurses Protective Society (CNPS) services, including its professional liability
protection, while lawfully engaged in the practice of nursing in Canada. The Association shares your
personal information with CNPS, including your email address, so that it may ascertain that you are
eligible for its services, provide you with services and communicate with you in respect to its services.
CNPS will use your email address for transactional purposes, such as communicating with you in
relation to services, responding to your email inquiries, informing you about changes to fees, and
providing you with information about important legal developments.
CNPS may also, with your consent, use your email address to provide you with other relevant forms of
electronic information from CNPS, including, but not limited to, information about webinars, legal
presentations and publications.
I give my consent to CNPS to use my email address to provide me with other such relevant
information.
I understand I may remove my consent from CNPS to use my email address for these other
information purposes at any time by selecting the UNSUBSCRIBE feature that accompanies the
communication or by contacting CNPS directly.
3 *I have read the eligibility for assistance provisions of the CNPS Bylaws. I understand that CNPS
professional liability protection is contingent upon practicing nursing in accordance with a valid
nursing license. I understand my obligation to cooperate with CNPS and report any claim or
adverse event at the earliest opportunity and cooperate with CNPS in the management of those
claims. I understand that CNPS services and, in particular, the provision of professional liability
protection and legal assistance, does not generally extend to my professional corporation or
business entity.
College of Registered Nurses of Manitoba
As a Practising member of the Association you are eligible for Canadian Nurses Protective Society
(CNPS) services, including its professional liability protection that is required by the College of
Registered Nurses of Manitoba (CRNM) to practice nursing. The Association shares your personal
information with CRNM, including your name, birth date, registration number and level of CNPS
protection (e.g. graduate nurse, registered nurse or nurse practitioner). CRNM will use the information
to confirm that you have the necessary professional liability protection (CNPS) to meet the
requirements to practice in the year in which you have applied to practice or renew your registration
to practice.
_________________________________________________ ______________________________
Signature Date
Please read this important information about your 2022 payment options
Pre-Authorized Payment Plan for 2022 fees
The Association offers a Pre-Authorized Payment Plan that sets up recurring payments on your credit
card to prepay your 2022 fees in 12 low payments. The first payment will be on November 1, 2020.
By the time next year’s renewal rolls around, yours will be complete.
Sign me up! I would like to register for the Pre-Authorized Payment Plan
Monthly Amount: $17.66 (amounts include GST & withdrawal fee)
Please note, we will charge the credit card used below for your 2022 pre-authorized payments unless
you let us know otherwise.
_________________________________________________ ______________________________
Signature Date
4Payment Options
Do not complete if you are paying in-person or sending the form via email
I am paying by:
Certified Money Interac Visa Mastercard E-transfer
cheque order (in person only)
Amount: RN/GN $199.97 (incl GST)
Please Note:
Complete the card information below if you are mailing the membership application or sending it
through fax (204) 219-3418. For email submissions, please call (204) 992-1520 for payment.
___________________________________________________ ________ / _________ _________
Card Number Expiry CSC
__________________________________________________________________________________
Cardholder Name
_______________________________________________ _________________________________
Authorizing Signature Date
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