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| GEM-Nursing Group E-Mentoring in Nursing |
| GEM-NURSING Mentor Registration Form Name: ________________________________________________________________________ Occupation: ____________________________________________________________________ Business / Organization: Georgia Association of Nursing Student (GANS) Address: _______________________________________________________________________ _______________________________________________________________________ City: ___________________________________ State: __________ ZIP Code: _____________ Is the address you provided: _____ home _____ work E-mail: ________________________________________________________________________ Daytime Phone: (_____) ____________________ Evening Phone: (_____) _________________ If we need to call you, which phone should we use: ____ Day _____ Evening _____ Either Fax number: (_____) ____________________________________ My gender is: _____ Female _____ Male Which of the following best describes your race? (Please check one.) _____ a. American Indian or Alaska Native _____ e. White or Caucasian, non-Hispanic _____ b. Asian / Pacific Islander _____ f. Bi-racial or Multi-racial. Please explain: _____ c. Black or African American _______________________________ _____ d. Hispanic / Latina _____ g. Other, please explain _____________ I hereby release and hold harmless, the United States Department of Labor Women's Bureau (Women's Bureau), for the use of my name, written or spoken words, photograph, picture, portrait, likeness, and voice (hereinafter collectively known as image) in order to operate, evaluate, and publicize the GEM-Nursing program (Group E-Mentoring in Nursing). This includes the right to use, reproduce, publish, exhibit, distribute, and transmit my image individually or in conjunction with other images or printed matter in the production of brochures, motion pictures, television tape, sound recording, still photography, CD-ROM, and other media. I understand that my image may be obtained through this application and through my participation in the Women's Bureau GEM-Nursing listserv, on the GEM-Nursing web site, or at any GEM-Nursing events held at the local, regional, or national levels. I have also read the mentor guidelines, and agreed to abide by them when using the Women's Bureau GEM-Nursing listserv and when participating in the GEM-Nursing program. ______________________________________________________ _____________________ Signature date Please attach or send via email a biography and picture for the website. Content suggestions can be found on the Mentor Guidelines. Electronic formats of biographies and pictures are preferable. |
| Please fax form to Women's Bureau Regional Office c/o Cindy Green glnconsultant@cs.com (706) 561-8330 fax |