Hospital Membership Application and Registration Form RAC-R FY 2027 (9/1/26-8/31/27)
Name of your Organization
*
Name of CEO or Chief
*
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from physical address)
*
P.O. Box
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer ID Number (EIN)
*
Has your facility attained trauma designation?
*
Yes
No
If your facility has attained trauma designation, select the level of designation.
*
Level I
Level II
Level III
Level IV
No trauma designation
Provide the Month / Year your designation expires. Enter NA if not applicable.
*
Provide the date or approximate date you will undergo re-verification. Enter NA if not applicable
*
Who has your Trauma Medical Director designated a representative to represent him/her at the RAC meeting?
*
Name of Trauma Medical Director
*
First Name
Last Name
Email of TMD
*
example@example.com
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Hospital Representative to the RAC
Name
*
First Name
Last Name
Title / Position
*
Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Representative to the RAC
Name
*
First Name
Last Name
Title / Position
*
Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact for Organization
Name
*
First Name
Last Name
Title / Position
*
Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Manager / Safety Officer for your Organization
Name
*
First Name
Last Name
Title / Position
*
Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
List the top 3 emergency management hazards in your county.
Hazard 1
*
Hazard 2
*
Hazard 3
*
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Primary Neonatal Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Neonatal Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Maternal Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Maternal Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Sepsis Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Sepsis Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Stroke Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Stroke Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Chest Pain Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Chest Pain Representative (enter NA in all fields if service is not available)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Who is the authorized person to commit the organization to membership in the RAC.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Email to submitter
*
example@example.com
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