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Assisted Living Membership Application

Assisted Living Membership Application

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Select the best description for your long-term or residential care community:
Address:(Required)
Does your community have a secure memory care unit/wing?(Required)
i.e. Administrator, General Manager, Executive Director, etc.
Best email address to send invoices.
Address: (if different from above)
Areas of Interest: Please check the areas where you are most interested:

As an authorized representative of the above-named facility, I hereby make application on behalf of the facility for status as a Regular Member of the Washington Health Care Association. I hereby certify the above-named facility is currently licensed by the state of Washington and has as its principal purpose the provision of residential care services. If accepted for membership, I pledge the facility will support WHCA's Bylaws and such codes of ethics and standards as may be established by the Board of Governors, and will ensure, to the best of my abilities, the provision of services consistent with Federal, State and Peer Review Standards. I hereby certify that I am aware of provision 2(c) of Article II of the WHCA Bylaws which states: "If a facility seeks membership, all facilities, portions, units or beds thereof under common control, ownership or operation which are located in the state of Washington must become members."

Consent to Receive Electronic Meeting Notices via Email(Required)

The undersigned hereby consents, pursuant to RCW 24.03.009 to receipt of notice by electronic transmission of correspondence regarding membership in the Washington Healthcare Association. Notice provided pursuant to this consent will meet the requirements of RCW 24.03. and will be considered effective when it is electronically transmitted to the address, location, or system provided by the member herein.

This consent may be revoked or amended at any time by the member and shall be deemed revoked if the Association is unable to transmit two consecutive notices in accordance with this consent and this ability becomes known to the Secretary/Treasurer of the Association or other person responsible for giving the notice.

You are applying for membership with Washington Health Care Association. By checking this box, you agree to pay membership dues and note that cancellation must be made in writing thirty days prior to cancellation effective date.(Required)
WHCA dues are based on the number of licensed assisted living beds in your facility. WHCA will look up the number of licensed beds by the license number you have provided in the DSHS database. If you feel the DSHS database information is incorrect, please contact our office at (800) 562-6170, extension 110.
I have read and understand the statement above re: WHCA dues:(Required)

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