Join the Coalition LinkedInThis field is for validation purposes and should be left unchanged.Organization Name/Facility Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility Phone Number*Point of ContactName* First Last Title/PositionEmail* Office PhoneMobile PhoneSecondary Point of ContactName* First Last Title/PositionEmail* Office PhoneMobile PhoneOrganization Type* Hospital Local Health Department Emergency Management Agency Emergency Medical Service Ambulatory Surgery Center Rural Health Clinic Skilled Nursing Facility Behavioral Health Organization Home Health Organization Hospice Dialysis/End Stage Renal Disease (ESRD) What Member Benefits Interest Your Organization? Networking with district healthcare emergency preparedness leadership and response officials Health surveillance and information sharing Ability to mobilize and coordinate medical resources Healthcare mass alert and communication coordination Access to and participation in district hazard vulnerability assessments Access to and participation in coordinated training and exercises that test organizational and district capabilities Centers for Medical Emergency Preparedness Rule Regulatory and accreditation requirements In what county is your organization located? Clark Dearborn Decatur Floyd Franklin Harrison Jefferson Jennings Ohio Ripley Scott Switzerland If your organization serves multiple counties please list them here.Would you like to be enrolled in the district's mass notification system, Alert Media? Yes, please enroll Not at this time
