Application for General Assembly Delegate

2016 Delegate Application

Name_____________________________________ ENA Membership #________________

Address___________________________________City_________________ Zip_________

E-mail address_______________@__________________Work Phone#                                               

Home Phone _________________________Cell Phone                                                                


The NH State Council By-Laws require that all potential delegates have attended at least 50% of all meetings, which will be verified.  Excused absences must have been approved by the Board within 30 days of the missed meeting.  Qualified applicants will be selected as Delegates based on the following point system.


Be sure to provide verification of all activities and positions as requested below. The NH-Board of Directors will verify activities and rule on any questions regarding qualified activities. 

Points are accumulated for activities from May 1, 2014 to April 30, 2015. 

Application and supporting materials must be submitted to no later than midnight, June 30, 2015. 


ENA Participation



Your Points

NH ENA meeting attendance (50% minimum required).  Circle meetings attended:

Jun 2014               Aug 2014              Oct 2014               Dec 2014              Feb 2015               Apr 2015

1 / meeting


NH-ENA Standing Committee Chair or Co-Chair  (Injury Prevention, Professional Practice, Gov’t Affairs, Education, TNCC, ENPC, Membership,  Webmaster, etc.)


*Points awarded per Board discretion based on fulfillment of charges.

Up to 4 *


Active NH-ENA Standing Committee member (to be validated by Chairs)


2 / Committee


Special Event Committees / Workgroups   (NH Annual Conference, Leadership Breakfast, etc)

Committee(s)/Work Group(s):________________________________________________________

Describe your role(s):       

Chair = 3 Member = 2


New England Regional Symposium   

Describe your role(s):        

Chair = 10 Member = 5


National ENA Committee / Work Group.  Attach roster listing your name.

Committee/Work Group:

Chair = 4 Member = 2


Special Projects— Mitten/hat collection, Emergency Nurses day flower delivery, etc. Describe the event(s) and your involvement:

2 each


Teaching Activities



TNCC Instructor

List dates/locations of courses:

1 each


TNCC Course Director (NH-ENA state courses only)

List dates/locations of courses:

2 each


ENPC Instructor

List dates/locations of courses:

1 each


ENPC Course Director (NH-ENA state courses only)

List dates/locations of courses:

2 each


Presenter at NH ENA meeting or conference

List date/topic of presentation(s):

1 each


Educational / Professional



Attend NH Yearly conference  (Attach copy of CE certificate)



Attend Scientific Assembly (Attach copy of CE certificate)



Attend NERS (Attach copy of CE certificate)



Attend other ENA sponsored education (Attach copy of CE certificate)

1 each


Current CEN, CPEN (Attach copy of card or certificate)

1 each


Current TNCC, ENPC (Attach copy of card)

1 each








I understand that if I accept a N.H. Delegate or Alternate position I am required to attend all parts of General Assembly and participate in any preparatory meetings or activities.  I also understand that my expenses (not to exceed $800) will be reimbursed upon presentation of an expense report and receipts.  If I am reimbursed for any expenses prior to General Assembly and then fail to attend as expected, I will return the money to NH-ENA unless a special (hardship) exception is approved by the NH-Board of Directors.


Signed:                                                                                                                       Date:                                                         



E-mail electronic documents to Stacey Savage at:


Mail hard copy documents to:

                    Stacey Savage

                    258 Center St.

                    Wolfeboro, NH 03894


Questions?  E-mail Stacey Savage, NH-ENA President at:


Application and supporting documents must be received by midnight

July 30, 2016