BCRAC Membership Application

Question Title

* 1. Organization/Individual Name

Question Title

* 2. Adress

Question Title

* 3. City

Question Title

* 4. Zip

Question Title

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

Question Title

* 6. Phone #

Question Title

* 7. Fax #

Question Title

* 8. Email address

Question Title

* 9. Cell phone capable of receiving text messages

Question Title

* 10. Alternate Designated Representative's Name - One Per Organization

Question Title

* 11. Phone #

Question Title

* 12. Fax #

Question Title

* 13. Email address

Question Title

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

Question Title

* 15. Email address for the person responsible for submitting Performance Improvement reports

Question Title

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

Question Title

* 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

Question Title

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

Individuals

Organizations (non-health related)

Question Title

* 19. Payment

Pay member dues from Tobacco Education grant

Mailing dues must be received by December 1

Question Title

* 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

Question Title

* 1. Organization/Individual Name

Question Title

* 2. Adress

Question Title

* 3. City

Question Title

* 4. Zip

Question Title

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

Question Title

* 6. Phone #

Question Title

* 7. Fax #

Question Title

* 8. Email address

Question Title

* 9. Cell phone capable of receiving text messages

Question Title

* 10. Alternate Designated Representative's Name - One Per Organization

Question Title

* 11. Phone #

Question Title

* 12. Fax #

Question Title

* 13. Email address

Question Title

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

Question Title

* 15. Email address for the person responsible for submitting Performance Improvement reports

Question Title

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

Question Title

Question Title

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

Question Title

* 19. Payment

Question Title

Question Title

* 21. Printed name of authorized signor

Question Title

* 22. Date

Question Title

* 23. Title

Question Title

* 24. Texas Hospital/provider license #

Question Title

* 25. Expiration date