KANSAS HEALTHCARE COALITIONS
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NOrth Central Kansas Healthcare Coalition
New Member REgistration
NCKS hcc New Member Registration Form
*
Indicates required field
Agency Name
*
Agency Type
*
Select One
Hospital
Public Health
Emergency Management
EMS
Religious Non-Medical Healthcare
Ambulatory Surgical Center
Hospice
Psychiatric Residential Treatment Facility
All Inclusive Care for the Elderly
Transplant Center
Long Term Care
Immediate Care Facility for Individuals with Intellectual Disabilities
Home Health Agency
Comprehensive Outpatient Rehabilitation Facility
Critical Access Hospital
Clinic, Rehabilitation Agency, and Public Health Agency as Provider of Outpatient Physical Therapy and Speech Language Pathology Services
Community Mental Health Center
Organ Procurement Organization
Rural Health Clinic and Federally Qualified Health Center
End-Stage Renal Disease Facility
Private Partner
Non-Governmental Organization (NGO) Partner
State Partner
Federal Partner
Law Enforcement Partner
Other
Agency County
*
Make a Selection
Clay
Cloud
Dickinson
Ellsworth
Jewell
Lincoln
Mitchell
Osborne
Ottawa
Republic
Saline
Smith
Choose the primary county your agency operates in.
Name
*
First
Last
Job Title
*
Agency Address
*
Line 1
Line 2
City
State
Zip Code
Country
Business Email
*
Office Phone
*
Fax Number
*
Fax is still a viable redundant communication tool.
Mobile Phone
*
Can you receive text messages on the mobile phone number you provided?
*
Yes
No
Does your agency have access to an 800 MHz Radio?
*
Yes
No
Unsure
Does your agency have access to WebEOC
*
Yes
No
Unsure
Does your agency have access to EMResource?
*
Yes
No
Unsure
Does your agency have access to eICS?
*
Yes
No
Unsure
Do you want access to member-only areas of our website?
*
Yes
No
If you answer yes, please watch for an email with a unique website registration link for the website. Check your junk mail folder if you do not see an email.
How did you hear about our coalition?
*
Website
Twitter
Other
If you selected other, please list how you heard about our coalition
*
Comments or Questions
*
Submit
Home
About
Conference
2023 Kansas Healthcare Coalition Summit
>
Exhibitor Registration
Attendee Registration
Event Schedule
Speakers
Media
HCC-101
Calendar
COVID-19
News
KanDrive Live Weather
KSMETRO
About KSMETRO
>
KSMETRO Leadership
Join KSMETRO
KSMETRO Member Only
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KSMETRO Member Directory
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Training Sessions
