MONTANA PARISH NURSE DIRECTORY INFORMATION FORM

We are in the process of creating a directory of active parish nurse sites from around the state.  We would appreciate your assistance in compiling the information for this directory.  Please update or correct as needed the information we do have about you, and fill in the remaining information as it pertains to your program. Thank you.

  First Name:   Last Name:
 Address:  City:  State:  Zip:
 Home Phone:   Work Phone:
 E-mail Address: 
 Year Completed Parish Nurse Prep. Program:  Nursing Degree:
  Church:   Church Address: 
  City:   State:   Zip:
 Church Phone:    Pastor's Name:
  Local Church web site address (if applicable): 
  Denomination web site address (if applicable):

Tell us about your church's Parish Nurse Program:

Do you have an active Parish Nurse Program at your church at this time?  _____  Yes    _____  No
     If yes, please answer the following questions:
Do you work as Paid ____  or Unpaid ____ staff?
Does your church have a budget for parish nurse/health ministry programs?  ____ Yes  ____ No
Are you reimbursed for mileage or other expenses?  ____ Yes  ____ No
     If yes, please explain: ________________________________________________________
Approximate number of hours worked each week: _____________
Please list the main activities of your Parish Nurse Program:

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Please check your preference:
______ Yes, you have my permission to post the shaded information in an on-line directory to be accessed through the Parish Nurse web page (www.carroll.edu/parishnurse), including highlights of my program.  (Please circle any other information we could post regarding your site.)
______ No, please include this information only in the printed directory available through the Parish Nurse Center.

Signature: __________________________________   Date: ________________________