VHEPC Organization Agreement Form

Vermont Healthcare Emergency Preparedness Coalition Member Application and Agreement
The Vermont Healthcare Emergency Preparedness Coalition (VHEPC) is multi-disciplinary partnership that collaborates with its members, stakeholders, and surrounding communities to improve and expand emergency preparedness, response, and recovery capabilities. The VHEPC works with healthcare entities to prepare for, respond to, and recover from emergencies in the state of Vermont.

The VHEPC is an inclusive body open to all organizations and entities that provide health services in the 14 counties of Vermont. The VHEPC 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, recover from consequences of a disaster.

Coalition membership is comprised of healthcare organizations, emergency medical services providers, emergency management agencies, public health professionals, jurisdictional entities, business and volunteer organizations within the State of Vermont.

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.
Applicant Full Name *

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Applicant Job Title*
Applicant Phone Number*
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Applicant Email*
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Organization Name*
Organization Address*

Street Address

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Organization Type*
What is your biggest reason for joining the coalition?

Networking/Information SharingTraining OpportunitiesExercisesPlan DevelopmentFunding OpportunitiesRequired to ParticipateOther
Do you have any recommendations for the Vermont Healthcare Emergency Preparedness Coalition that would assist your organization?
Organization Agreement

Coalition members are expected to fulfill these responsibilities:
- Provide representation at coalition meetings
- Participate in coalition activities
- Join at least one active coalition workgroup
- Participate in collaborative preparedness efforts
- Participate in the development of surge capacity plans, inter-organizational agreements and collaborative emergency response plans
- Vote on coalition activities and elections
- Respond, as able, to regional emergencies and disasters in collaboration with other coalition members
By signing below, the signatory organization agrees to the expectations of the Vermont Healthcare Emergency Preparedness Coalition members and to support the mission and purpose of the coalition.
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Vermont Healthcare Emergency Preparedness Coalition Member Application and Agreement