BCRAC Membership Application

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* 1. Organization/Individual Name

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* 2. Adress

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* 3. City

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* 4. Zip

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* 5. Primary Designated Representative's Name - One Per Organization

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* 6. Phone #

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* 7. Fax #

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* 8. Email address

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* 9. Cell phone capable of receiving text messages

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* 10. Name of the person responsible for submitting Performance Improvement reports (not applicable to FRO)

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* 11. Email address for the person responsible for submitting Performance Improvement reports

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* 12. Alternate Designated Representative's Name - One Per Organization

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* 13. Phone #

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* 14. Fax #

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* 15. Email address

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* 16. What educational course would be most beneficial to your agency through RAC-sponsored training opportunities

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* 17. MEMBER CLASSIFICATION & FEES
According to BCRAC Bylaws, annual dues (September - August) are assessed based on your classification with
the Texas Department of State Health Services. Please check one of the following, filling in your calculated fees
based on your associated bed/ambulance/asset information as applicable:
VOTING MEMBERSHIP $200

Hospital/medical Facilities

EMS/Ambulance

Air Ambulance

Schools and Colleges

Physicians Groups

Professional Associations

First Responders/Volunteer

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* 18. Associate (Non-voting) Members: $50

Individuals

Organizations (non-health related)

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* 19. Payment

Pay member dues from Tobacco Education grant

Mailing dues must be received by December 1

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* 20. I/my organization acknowledge(s) responsibilities as a member and essential component of the emergency healthcare system
established by the State of Texas for the sixteen counties comprising Trauma Service Area - D. I affirm its/my, willingness to comply, as appropriate, with state and/or regional guidelines, obligations and by-laws as presented by the Big Country Regional Advisory Council (BCRAC) and its Board, generally found at WWW.BigcountryRAC.org

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* 1. Organization/Individual Name

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* 2. Adress

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* 3. City

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* 4. Zip

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* 5. Primary Designated Representative's Name - One Per Organization

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* 6. Phone #

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* 7. Fax #

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* 8. Email address

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* 9. Cell phone capable of receiving text messages

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* 10. Name of the person responsible for submitting Performance Improvement reports (not applicable to FRO)

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* 11. Email address for the person responsible for submitting Performance Improvement reports

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* 12. Alternate Designated Representative's Name - One Per Organization

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* 13. Phone #

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* 14. Fax #

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* 15. Email address

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* 16. What educational course would be most beneficial to your agency through RAC-sponsored training opportunities

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* 18. Associate (Non-voting) Members: $50

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* 19. Payment

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* 21. Printed name of authorized signor

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* 22. Date

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* 23. Title

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* 24. Texas Hospital/provider license #

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* 25. Expiration date