VHAC Participant Registration & Engagement Form

VHAC Participant Registration & Engagement Form

Thank you for participating in VHAC. This form helps us accurately track attendance by site, agency, and region while also confirming how you would like to stay connected with VHAC. Your responses will help us standardize naming conventions, improve regional follow-up, and ensure you receive the meeting invitations, workgroup updates, and communications most relevant to you.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
VHAC REGION
Refer to VHAC Map if unsure.
Participant Type:
Are you representing more than one Healthcare System and/or EMS Agency?
Health System Name
Health System Name(s)

Other
EMS Agency
EMS Agencies

Other
Healthcare Facility/Agency Name (use if not listed in the above)
Site Name (s), if applicable
Please select any VHAC communications or groups you would like to be added to:
If you selected “VHAC Workgroups,” please choose the workgroup(s) you are interested in:
Permission to share contact information with Regional Leads
Should be Empty: