Please print out, complete and return this portion to the membership chair if you are interested in becoming or having a mentor for the next school year. Return the form to one of the following:
	Co-Membership/Mentor Chairs Kristine Dauerhauer West Junior High School 1921 27th Avenue South Wisconsin Rapids, WI 54495 kris.dauerhauer@wrps.org 715-422-6196
_______   Yes, I would like to be a mentor.
_______   Yes, I am a new school nurse and would like to have a mentor.
_______   Yes, I am a new school nurse and would like the Welcome Packet.
Name:__________________________________
School district: ___________________________________
Home phone: ( ) ___________________
Work phone: ( ) ___________________
Home address ________________________________________
Work address ________________________________________