Everbridge Facility Registration Question Title * 1. Do you currently have an Everbridge Login? Yes No OK Question Title * 2. Is your facility currently using Everbridge? Yes No OK Question Title * 3. What is the name of your facility? OK Question Title * 4. Please select your Healthcare Coalition Region? Region A - Catoosa, Dade, Fannin, Gilmer, Gordon, Murray, Pickens, Walker, Whitfield Region B - Banks, Dawson, Habersham, Hall, Lumpkin, Rabun, Stephens, Towns, Union, White Region C - Bartow, Carroll, Chattoga, Coweta, Floyd, Haralson, Heard, Polk Region D - Clayton, Fayette, Forsyth, Fulton, Gwinnett, Newton, Rockdale Region E - Barrow, Clarke, Elbert, Franklin, Greene, Hart, Jackson, Madison, Morgan, Oconee, Oglethorpe, Walton Region F - Bibb, Butts, Crawford, Henry, Houston, Jones, Lamar, Monroe, Peach, Pike, Spalding, Upson Region G - Burke, Columbia, Emanuel, Glascock, Jefferson, Jenkins, Lincoln, McDuffie, Richmond, Taliaferro, Warren, Wilkes Region H - Baldwin, Bleckley, Dodge, Hancock, Jasper, Johnson, Laurens, Montgomery, Pulaski, Putnam, Telfair, Treutlen, Twiggs, Washington, Wheeler, Wilcox, Wilkinson Region I - Chattahoochee, Clay, Crisp, Dooly, Harris, Macon, Marion, Meriwether, Muscogee, Quitman, Schley, Stewart, Talbot, Taylor, Troup, Webster Region J - Bryan, Bulloch, Camden, Candler, Chatham, Effingham, Evans, Glynn, Liberty, Long, McIntosh, Screven, Tattnall, Toombs Region K - Baker, Brooks, Calhoun, Colquitt, Decatur, Dougherty, Early, Grady, Lee, Miller, Mitchell, Randolph, Seminole, Sumter, Terrell, Thomas, Worth Region L - Ben Hill, Berrien, Cook, Echols, Irwin, Lanier, Lowndes, Tift, Turner Region M - Appling, Atkinson, Bacon, Brantley, Charlton, Clinch, Coffee, Jeff Davis, Pierce, Ware, Wayne Region N - Cherokee, Cobb, Douglas and Paulding OK Question Title * 5. Please enter name of a contact person for your facility? OK Question Title * 6. Please enter an email address for the person named in question 3? OK Question Title * 7. Please choose your facility type Assisted Living Facility Community Health Centers Dialysis Services EMS Home Care Hospice Nursing Home Outpatient Surgery Center Personal Care Home Public Health Support Agency/Organization OK Question Title * 8. Please choose the role for your contact person Managing Contacts and sending messages Sending Messages Only OK Question Title * 9. Other comments OK DONE
