WisPQC Membership Application

Official Name of Organization*

Name as you would like it to appear in WisPQC materials.

Website

Upload Organization Logo

Drop files here or

Accepted file types: jpg, gif, png, Max. file size: 32 MB.

*Please Note: Membership will not be confirmed without the ability of the WisPQC to use your organization's logo on WisPQC materials.

Address*

Street Address Address Line 2 City State ZIP Code

Is your organization a hospital?*

Yes
No

Has your facility completed the WAPC Levels of Care self-assessment surveys?

Yes
No

For more information on the WAPC Levels of Care initiative, go to the WAPC Web site, or call WAPC staff at 608-285-5858.

What level obstetric services do you provide?

Level I
Level II
Level III
Level IV
We do not provide obstetric services.

What level neonatal services do you provide?

Level I
Level II
Level III
Level IV
We do not provide neonatal services.

Representative Contact Information

Contact information for the designated representative who will be attending monthly meetings, via Webinar or face-to-face:

Name*

Email*

Phone*

Alternate Contact Information

Contact information for possible alternate(s) who may be representing your organization instead of the designated representative.

Name

Email

Phone

Do you have another alternate name to add?*

Yes
No

Second Alternate Name

Email

Phone

Do you have another alternate name to add?*

Yes
No

Third Alternate Name

Email

Phone

Do you have another alternate name to add?*

Yes
No

Fourth Alternate Name

Email

Phone

Use the space below to share how you heard about WisPQC and who and/or what was most significant encouraging/supporting your involvement.*

Electronic Signature

Accepted file types: jpg, gif, png, Max. file size: 32 MB.

If available, the electronic signature of staff with authority to commit to membership of your organization. *Files must be no larger than 2MB.

Typed Name of Signer*

Date*