Membership NCCNHR MEMBERSHIP APPLICATION Send or fax completed form to NCCNHR, 1828 L Street, NW, Suite 801, Washington, D.C. 20036 or fax. 202-332-2949. NCCNHR: The National Consumer Voice for Quality Long-Term Care is a non-profit advocacy organization dedicated to improving the quality of life and care for all persons in long-term care facilities and those receiving long-term care in the community setting.
We are consumers and advocates who define and achieve quality for people with long-term care needs. We accomplish quality through: · informed, empowered consumers; · effective citizen groups and ombudsman programs; · promoting best practices in care delivery; · public policy responsive to consumer needs; and · enforcement of standards that promote quality.
You can help NCCNHR help residents. Use the form below to join as a group or individual, or to subscribe to our newsletter, the Quality Care Advocate. With annual membership, you receive:
Individual Memberships Resident ............................................. $ 2 Students/Nursing Assistants ................. $10 Age 65 and over ................................. $25 Other Individuals.................................. $40 Licensed Professional........................... $65 NALLTCO/NCCNHR Joint Membership........... $50
Tax-Deductible Donations $_____________ Donation in memory of / in honor of: (circle one) ______________________________________
Group Memberships Resident Councils...................................... $ 5 Family Councils......................................... $ 35 Budget under $25,000 .............................. $ 45 Budget $25,001 - $75,000 ....................... $ 75 Budget $75,001 - $150,000 ..................... $145 Budget $150,001 - $500,000 ................... $200 Budget $500,001 - $2 million.................... $350 Budget over $2 million .............................. $500
Name:
Title: _________________________________
Organization: ____________________________
Street Address: ________________________
City/State/Zip: ________________________
Phone: ( _______) - _____________________
Fax: ( ) - ________________________
Email Address: _____________________________
Total Amount to be Paid: ______________________
Payment Method: (check one)
Acct. #: ____________________Exp: _________
Cardholder's name: ________________________ (please print) Cardholder's Signature: _______________________
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