Membership Information
Membership Form – Calendar Year 2007
Please type or print legibly
Annual Membership Fee: The annual fee for Chapter membership includes two options. Option 1 is a one time annual fee of $75.00 that includes all meetings. Option 2 includes a one-time fee of $30.00 payable in advance and an additional $20.00 to be paid at every meeting attended. The enrollment year is January through December.
Date: _________________________
Name: __________________________________________ Title: __________________________
Healthcare organization: ___________________________________________________________
Business address: ________________________________________________________________
Business: Telephone: (_______)__________________________________
Fax #: (_______)__________________________________
E-mail address: _________________________________________
Home (optional, for official use only): Telephone: (_______)________________________
E-mail address: _______________________________
PLEASE COMPLETE THE FOLLOWING DEMOGRAPHICS:
1. Are you a member of our national society, the Society for Healthcare Consumer Advocacy?
______Yes _______No
2. What is the title of the person to whom you report? ____________________________________
3. Activities for which you are responsible (check ALL that apply):
1. ____ One person program 10. ____ Volunteer services
2. ____ Advance directives 11. ____ Employee rewards/recognition
3. ____ Concern management 12. ____ Training and development
4. ____ Patient satisfaction surveys 13. ____ Notary
5. ____ Lost and found 14. ____ Marketing
6. ____ Risk management 15. ____ Community activities
7. ____ Ethics committee 16. ____ Quality assurance
8. ____ Patient rights and responsibilities 17. ____ Other (explain) ______________________
9. ____ Recipient Rights ____________________________________________
NOTE: Please return your completed application and membership fee to our Treasurer/Membership Chair: Ms. Robin Nelson; Patient Relations Manager; MidMichigan Medical Center-Midland; 4005 Orchard Dr.; Midland, Michigan 48670. Checks should be made payable to the MCSHCA.