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Register Your New DAISY Coordinator or Chief Nursing Officer

Thank you for providing information about your new DAISY Coordinator or CNO. We appreciate your completing the entire form, even if some of the information is not new to you or your organization. This will ensure that our records up to date, facilitate a smooth transition, and get your DAISY Award gifts to you .

VERY IMPORTANT: Please inform your IT Department to allow all emails from DAISYFoundation.org to reach you as most of our communication is via email.

Name of your healthcare organization or facility: *

City: *

State/Province: *

Country: *

Tell us about your DAISY Coordinator

We have a new DAISY Coordinator as of (effective date):

First name: *

Last name: *

Credentials:

Title:

Email:

Phone (555 555 5555):

DAISY Award Shipping Information

Please confirm where you want your DAISY Award gifts shipped so our shipping label is correct:

Ship to Name:

Ship to Title:

Ship to Email:

Ship to Phone (555 555 5555): (555 555 5555)

Ship to organization name (i.e. your hospital or other healthcare organization name):

Ship to Unit, Floor, Mailstop (Whatever we need to deliver to you):

Ship to Street (No PO box please):

Ship to City:

Ship to State:

Zip code:

Country:

If not in the USA, please type the entire address as it should appear on a shipping label here, including the entire phone, fax number and email address of the package recipient:

Tell Us About Your CNO (to be sure your DAISY Award Certificate template is correct)

CNO first name:

CNO last name

CNO credentials:

CNO exact job title:

CNO email:

CNO phone (555 555 5555): (555 555 5555)

In case we have questions, who submitted this form?

Name: *

Email: *

Is there anything else we should know?

Our goal is to continue to make The DAISY Award Program an important and special part of being a nurse at your facility. If you have registered a new DAISY Coordinator, we will call in the next week to help answer any questions he/she may have in taking over The DAISY Award Program.

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