GHC911 Facility Registration Request Survey

1.Please select your Healthcare Coalition Region(Required.)

2.Please choose your facility type(Required.)

3.Please fill out the basic contact information about your facility(Required.)

Facility Name

Medicare Number (If applicable)

Facility Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Website

Facility Phone Number

4.Please fill out the following contact information. These are required if you have them.

24 hour telephone number

24 hour email

Emergency Contact Name

Emergency Contact Number

Patient Transfer Number

Southern Linc Number

5.Please fill out your contact information

Your Name

Your Email

Your Phone

6.Volunteer Information

Volunteer Coordinator Name

Volunteer Coordinator Phone Number

Volunteer Coordinator Email