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

*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?*

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

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?

What level neonatal services do you provide?

Representative Contact Information

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

Name*

Email*

Phone*

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?*

Second Alternate Name

Email

Phone

Do you have another alternate name to add?*

Third Alternate Name

Email

Phone

Do you have another alternate name to add?*

Fourth Alternate Name

Email

Phone

Electronic Signature

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*