To join the Nurse Alert system please fill in the information below or fill out a paper copy and fax to (907) 272-0292

[Click here to download the PDF version]

All information is confidential and will not be sold or released to a third party who is not an ANAS partner.

All fields in red are required

First Name
Last Name
LPN License Number
RN License Number
RN Area of Experience
Hold the control key to select more than one item
RN Area of Certification
Nurse Practitioner Number
Nurse Practitioner Area of Experience
Nurse Practitioner Area of Certification
Check if you have liability insurance
Email
Address
Address (continued)
Zip Code
City
 "
Home Phone
Work Phone
Cell Phone
Fax Number
Employer
Position
Work Schedule
Other Certifications - Current
Hold the control key to select more than one item
Other Certifications - Past
Hold the control key to select more than one item
Language Fluency (besides English)
Language #2
Language #3
Check if you can travel up to 2 weeks
Check if can travel more than 2 weeks
Check if you may have child care issues

 

Please check ALL levels of care for which you are
currently skilled to provide.
Persons who are independent and capable of self-care requiring only minimal support for minor illness and injuries.
Level 1
Persons with conditions requiring observation or minor supportive assistance in activities of daily living. Independent with some family / caretaker support.
Level 2
Persons with conditions requiring some level of privacy or separation but do not require skilled or continuous health care from facility staff.
Level 3
Persons requiring frequent or continuous surveillance for potentially life threatening conditions or requires bedding or bathroom facilities not available in the shelter.
Level 4
Persons requiring skilled care, continuous observation, or special equipment and services usually found in a hospital.
Level 5