GHC911 Facility Registration Request

Please enter the information below if you would like to add your facility to GHC911. We will create the account and let you know when it is complete.

Please direct all questions and inquiries to
Selelia Jiles
O: 770.249.4506
E: sjiles@gha.org

Facility Name

Medicare Number (If applicable)

Facility Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Website

Facility Phone Number

24 hour telephone number

24 hour email

Emergency Contact Name

Emergency Contact Number

Patient Transfer Number

Southern Linc Number

Your Name

Your Email

Your Phone

Volunteer Coordinator Name

Volunteer Coordinator Phone Number

Volunteer Coordinator Email