San Francisco County Team

If a membership has been purchased for you, please enter your information below. Once your application has been submitted, you’ll have access to the members’ only area once approved.

Price:

Free for access until October 1, 2022

First Name:* First Name Required

Last Name:* Last Name Required

Phone:* Phone is Required

Street Address:* Street Address is Required

City:* City is Required

State:* State is Required

Zip Code:* Zip Code is Required

County Where Exams Performed:* County Where Exams Performed is Required

AlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYubaOther (Fill in Below)

List additional counties you practice in: List additional counties you practice in is not valid

Your Title:* Your Title is Required

Make a selectionRNNPPAMD

Professional License Number:* Professional License Number is Required

Expiration Date:* Expiration Date is Required

Are you an examiner currently active with a sexual assault forensic exam (SAFE/SANE) team?:* Are you an examiner currently active with a sexual assault forensic exam (SAFE/SANE) team? is Required

Yes No In Process

Name of Exam Team or Hospital:* Name of Exam Team or Hospital is Required

Exam Team Coordinator or Director:* Exam Team Coordinator or Director is Required

Coordinator or Director's Email Address:* Coordinator or Director's Email Address is Required

Coordinator or Director Phone:* Coordinator or Director Phone is Required

How Long Have You Been An Examiner:* How Long Have You Been An Examiner is Required

Less Than 1 Year1 to 5 Years5 or More Years

How Many Exams Have You Completed (Approximately):* How Many Exams Have You Completed (Approximately) is Required

Less Than 1010 to 100100 or More

Team Name (If purchased): Team Name (If purchased) is not valid

Your Gender:* Your Gender is Required

Make a selectionMaleFemaleTransgender FemaleTransgender MaleGender non-conforming/non-binaryDecline to stateOther (Fill in Below)

If you selected other option to provide more information: If you selected other option to provide more information is not valid

Your Race/Ethnicity:* Your Race/Ethnicity is Required

Make a selectionWhiteHispanic or LatinexBlack or African AmericanAmerican IndianAsianNative Hawaiian or Pacific IslanderDecline to stateOther (Fill in Below)

If you selected other option to provide more information: If you selected other option to provide more information is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

 

No val Please fix the errors above