SLVHCC Member Application and Agreement

The San Luis Valley Healthcare Coalition (SLVHCC) is a multi-disciplinary partnership that brings together healthcare organizations and response partners to strengthen emergency preparedness, response, recovery, and resilience through the San Luis Valley (SLVH) and the State of Colorado.

The SLVHCC collaborates with healthcare organizations, public health agencies, emergency management, emergency medical services, and other partners to improve the region's ability to prepare for, respond to, and recover from emergencies and disasters.

Membership is open to organizations and entities that provide or support healthcare and medical services within the six-county SLV region, including Alamosa, Conejos, Costilla, Mineral, Rio Grande, and Saguache counties. SLVHCC members share a common commitment to reducing the impact of emergencies on the SLV's healthcare system and improving coordinated planning, response, and recovery efforts.

By completing and signing this Membership Application and Agreement, your organization becomes an official member of the SLVHCC.

This agreement is not legally binding. Rather, it represents a good-faith commitment to actively participate in the SLVHCC, collaborate with fellow members, and support regional healthcare preparedness and response efforts whenever possible. All participation and support activities are understood to occur within each member organization's statutory authority, jurisdictional responsibilities, organizational policies, and Emergency Operations Plan(s).

As a SLVHCC member, your organization agrees to:

Attend General Membership meetings, whenever possible.
Participate in SLVHCC planning, training, exercises, and other activities.
Contribute to the development and review of SLVHCC plans, procedures, and other documents.
Participate in SLVHCC voting, including elections and other membership decisions.
When requested and able, support regional emergency response and recovery efforts in collaboration with other SLVHCC members.
Promote and implement emergency preparedness, response, and recovery capabilities within your own organization.
Maintain current organizational contact information and update SLVHCC documentation, as requested.
Support the mission, goals, and collaborative spirit of the SLVHCC.

For more information on membership responsibilities and requirements, please refer to the SLVHCC Bylaws.

Organization Name

Please do not use any abbreviations or acronyms

Organization Type

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address is Different Than Physical Address

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Representative Name

First NameLast Name

Primary Representative Title

Email

example@example.com

Primary Representative Business Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Can this phone number receive texts?

Primary Representative After-Hours/Emergency Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Can this phone number receive texts?

Although the Primary Representative listed above is responsible for fulfilling the membership duties outlined in the SLVHCC Bylaws, an alternate representative may be selected as a backup for membership duties, such as voting.

Would you like to include an alternate representative for your organization?

Alternate Representative Name

First NameLast Name

Alternate Representative Title

Alternate Representative Email

example@example.com

Alternate Representative Business Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Can this phone number receive texts?

Alternate Representative After-Hours/Emergency Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Can this phone number receive texts?

I understand that the Primary Representative listed above will be responsible for representing my organization to the SLVHCC and for sharing SLVHCC information with appropriate members of my organization.

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

I understand that regular attendance at SLVHCC meetings is required to keep my organization's membership in Good Standing.

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

By signing below, the authorized representative acknowledges that they are signing on behalf of their organization, affirms their organization's commitment to the Coalition's mission and principles, and understands that their organization will be recognized as an official member of the SLVHCC.

Please Type Your Full Name as Signature

Signature

SLVHCC Member Application and Agreement

Member Organization Information

Organization Representatives