Collier Healthcare Emergency Preparedness Coalition Membership Application

Mission Statement:

The mission of the Collier Healthcare Emergency Preparedness Coalition (CHEPC) is to promote and enhance the healthcare emergency preparedness and response capabilities of Collier County through collaboration of all coalition members.

Agency

First Name

Last Name

Agency Type

Phone Email

Current Role

Secondary Contact

Phone Email

Current Role

How can the Coalition help your organization?

CHEPC Membership Application Revised 10.30.18

Collier Healthcare Emergency Preparedness Coalition Membership Application

TERMS OF MEMBERSHIP:

By filling out this form I agree to:

Regularly participate in Coalition meetings.

Participate in surveys or other data gathering requests to assist with coalition training and preparedness goals.

Participate in Coalition communication drills.

Comply with Coalition bylaws.

I attest I have read the terms of membership and give my permission for the applicant(s) to represent this agency in the Collier Healthcare Emergency Preparedness Council.

CHEPC Membership Application Revised 10.30.18

XPrimary Applicant Signature and Date

XSecondary Applicant Signature and Date

XSupervisor Signature and Date