Board/Committee Member Reimbursement Form - Ohio Chapter of the National Association for Pediatric Nurse Practitioners

Ohio Chapter Member Spotlight Online Submission Form

Your Name(Required)

First Last

Your Credentials(Required)

What are your credentials? (e.g., DNP, APRN, CPNP-AC/PC or BSN, RN)

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

What is Your Membership Status? (select one):(Required)

*Membership Types: https://www.napnap.org/membership-choices/

Member (Preferred, Essentials, or Retiree)

Student Member (Career Starter/Student)

I am not a member

Are You Spotlighting Another Person?(Required)

Yes

If “yes,” what is the full name AND credentials of the person you’re spotlighting?(Required)

Please write the first and last name AND list credentials of the person you’re spotlighting (e.g., Shannon White, DNP, APRN, FNP-BC):

What is the membership status of the person you are spotlighting? (select one):(Required)

*Membership Types: https://www.napnap.org/membership-choices/

Member (Preferred, Essentials, or Retiree)

Student Member (Career Starter/Student)

Unsure (Note: The person being spotlighted must be a current member of the Ohio Chapter)

Spotlight Yourself or Another Member

Please write a short paragraph about yourself (or another member):

Member Spotlight:(Required)

Multi-File Upload

Please upload a photograph of yourself or the member you are spotlighting. Alternatively, you may upload an image or document with the requested information.

Drop files here or

Max. file size: 50 MB.

Privacy and Consent(Required)

Terms of Use and Conditions:

These Terms of Use govern the submission, use, and publication of content submitted through the Ohio Chapter of the National Association of Pediatric Nurse Practitioners’ Member Spotlight form.

1. Purpose of Use: Submitted information, including photographs and written content, may be used by the Ohio Chapter of NAPNAP for the purposes of promoting, highlighting, and celebrating member achievements. This may include publication on the Ohio Chapter website, member emails, newsletters, official social media channels, and promotional or educational materials.

2. Ownership and Rights: By submitting this form, you affirm that: The content and photographs are your own, or you have obtained the necessary permissions from the individual(s) featured.

You grant Ohio NAPNAP the non-exclusive, royalty-free right to use, reproduce, edit, and distribute the submitted content in digital or print form, with credit given to you or the featured member where appropriate.

No monetary compensation will be provided for submissions used in the Ohio Chapter's publications or communications.

3. Privacy and Consent: The Ohio Chapter will store and handle all submitted information in accordance with applicable privacy standards. Submitted content will only be used as described above and will not be sold or shared with third parties.

4. Consent Withdrawal: You may withdraw your consent at any time by contacting [email protected]. Upon withdrawal, the Ohio Chapter will make reasonable efforts to remove your content from future use. However, previously published material (e.g., newsletters or archived web content) may not be retracted once distributed.

5. Edits and Modifications: The Ohio Chapter reserves the right to make minor editorial changes (e.g., grammar, spelling, and formatting) to submitted content for clarity and consistency while preserving the original message.

I have read and agree to the Terms of Use and Conditions, including the Privacy and Consent Policy. I understand that by submitting this form, I am granting permission for the use of the submitted information and materials in accordance with these terms.

Name

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