Everbridge Facility Registration

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* 1. Do you currently have an Everbridge Login?

Yes

No

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* 2. What is the name of your facility?

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* 3. Please select your Healthcare Coalition Region

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* 4. Please enter name of a contact person for your facility

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* 5. Please enter an email address for the person named in question 4

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* 6. Please choose your facility type

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* 7. Please choose the role for your contact person

Managing contacts and sending messages

Sending messages only

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* 8. Other Comments