Join The Coalition Membership Form Step 1 of 3 33% Organization Name/Facility Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone* Point of ContactName* First Last Title/Position Email* Office PhoneMobile Phone Secondary Point of ContactName* First Last Title/Position Email* Office PhoneMobile PhoneOrganization Type* Hospital Local Health Department Emergency Management Agency Emergency Medical Service Ambulatory Surgery Center Rural Health Clinic Skilled Nursing Facility Behavioral Health Organization Home Health Organization Hospice Dialysis/End Stage Renal Disease (ESRD) What Member Benefits Interest Your Organization? Networking with district healthcare emergency preparedness leadership and response officials Health surveillance and information sharing Ability to mobilize and coordinate medical resources Healthcare mass alert and communication coordination Access to and participation in district hazard vulnerability assessments Access to and participation in coordinated training and exercises that test organizational and district capabilities Centers for Medical Emergency Preparedness Rule Regulatory and accreditation requirements CAPTCHANameThis field is for validation purposes and should be left unchanged.
