SLVHCC Member Application and Agreement Form

Organization Name (no abbreviations) *

Organization Type*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Representative Name*

First NameLast Name

Primary Representative Title*

Primary Representative NIMS Certifications*

	Not Completed	Completed	Date Completed
100
200
700
800
300
400

Primary Representative Business Phone Number*

Please enter a valid phone number.

Can receive texts?*

YesNo

Primary Representative Emergency/After Hours Phone Number*

Please enter a valid phone number.

Can receive texts?*

YesNo

Primary Representative Email*

example@example.com

Alternate Representative Name

First NameLast Name

Alternate Representative Title

Alternate Representative NIMS Certifications

	Not Completed	Completed	Date Completed
100
200
700
800
300
400

Alternate Representative Business Phone Number

Please enter a valid phone number.

Can receive texts?

YesNo

Alternate Representative Emergency/After Hours Phone Number

Please enter a valid phone number.

Can receive texts?

YesNo

Alternate Representative Email

example@example.com

I understand the Primary Representative listed above will be responsible to represent my organization to the SLV Healthcare Coalition, and to share SLV Healthcare Coalition information with the appropriate members of my Organization.*

I understand.

I understand that the Primary Representative will be expected to participate in Coalition-wide meetings, communication drills, and other emergency preparedness activities on at least a quarterly basis.*

I understand.

I understand that regular attendance at SLV Healthcare Coalition meetings is required to keep my organization's membership in Active Standing.*

I understand.

I understand that one or more members of my organization's local executive team may be expected to participate in SLV Healthcare Coalition activities on occasion, particularly following an exercise or a real Coalition emergency incident.*

I understand.

The San Luis Valley Healthcare Coalition (SLVHCC) is a multi-disciplinary partnership that collaborates with its members, stakeholders, and surrounding communities to improve and expand emergency preparedness, response, and recovery capabilities. The SLVHCC works with healthcare entities to prepare for, respond to, and recover from emergencies in the San Luis Valley Region and state of Colorado.

The SLVHCC is an inclusive body open to all organizations and entities that provide health services in its six (6) county region which include Alamosa, Conejos, Costilla, Mineral, Rio Grande, and Saguache Counties. The SLVHCC consists of organizations with responsibilities to mitigate the likelihood of a hazard negatively impacting the ability of a health and medical system to provide services and to prepare for, respond to, and recover from consequences of a disaster.

Coalition members will support health and medical response and recovery activities within the parameters of statutory authority, jurisdictional and/or organizational Emergency Operations Plans and as defined in within the principles of emergency management.

Coalition members are expected to fulfill these responsibilities:

Attend General Membership meetings
Participate in SLVHCC activities
Participate in the development of Coalition documents
Vote on Coalition activities and elections
When requested and as able, respond to regional emergencies and disasters in collaboration with other Coalition members
Work to implement emergency preparedness and response capability guidelines within the representative’s own organization
Update all applicable communication platforms, as requested

The signatory organization agrees it is a San Luis Valley Healthcare Coalition member and it supports the purpose of the Coalition.

Name*

First NameLast Name

Signature *

SLVHCC Member Application and Agreement Form

Member Application

Member Agreement