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Residential Care Home Membership Application
Membership – Residential Care Home
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Email:
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Fax:
VHCA Designated Voting Rep.:
Owner/Affiliation:
Address:
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Nebraska
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New Jersey
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
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Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
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Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Website:
Tax Status:
For-Profit
Non-Profit
Hospital Based
Year Established:
# Currently on Staff (all dept.):
Residential Care Beds: Level 3
Residential Care Beds: Level 4
Additional Info:
ERC Waiver Beds
VA Approved
ACCS Certified
Accept SSI
Services Provided:
Alzheimer/Dementia
Wheelchair Equipped Van
Hospice Program
Security Alert System
Palliative Care
Respite Care
(please check all that apply)
Department Heads
Administrator Name:
Email:
Director of Nursing Name:
Email:
Activity Director Name:
Email:
Dietary Director Name:
Email:
Social Services Director Name:
Email:
Maintenance Director Name:
Email:
Medical Director Name:
Email:
Comments or Questions:
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