1.Organization/Individual Name

2.Adress

3.City

4.Zip

5. Primary Designated Representative's Name - One Per Organization

6.Phone #

7.Fax #

8.Email address

9.Cell phone capable of receiving text messages

10.Name of the person responsible for submitting Performance Improvement reports (not applicable to FRO)

11.Email address for the person responsible for submitting Performance Improvement reports

12.Alternate Designated Representative's Name - One Per Organization

13.Phone #

14.Fax #

15.Email address

16.What educational course would be most beneficial to your agency through RAC-sponsored training opportunities

17.MEMBER CLASSIFICATION & FEES 
According to BCRAC Bylaws, annual dues (September - August) are assessed based on your classification with 
the Texas Department of State Health Services.  Please check one of the following, filling in your calculated fees
based on your associated bed/ambulance/asset information as applicable:
VOTING MEMBERSHIP $200

Hospital/medical Facilities

EMS/Ambulance

Air Ambulance   

Schools and Colleges

 Physicians Groups

Professional Associations

First Responders/Volunteer     

18.Associate (Non-voting) Members:  $50

Individuals

Organizations (non-health related)

19.Payment

Pay member dues from Tobacco Education grant

Mailing dues must be received by December 1

20.I/my organization acknowledge(s) responsibilities as a member and essential component of the emergency healthcare system
established by the State of Texas for the sixteen counties comprising Trauma Service Area - D.  I affirm its/my, willingness to comply, as appropriate, with state and/or regional guidelines, obligations and by-laws as presented by the Big Country Regional Advisory Council (BCRAC) and its Board, generally found at WWW.BigcountryRAC.org

Check the box acknowledging you accept the terms of this membership application

21.Printed name of authorized signor

22.Date

23.Title

24.Texas Hospital/provider license #

25.Expiration date