Membership Agreement — South Dakota Health Care Association

SDHCA/SDALA 2024-2025 Membership Agreement

FOR ACCURACY, PLEASE COMPLETE THE INFORMATION BELOW IN THIS FILLABLE FORM & RETURN TO SDHCA
804 N Western Avenue, Sioux Falls, SD 57104 EMAIL: sdhca@sdhca.org

Download Form

Facility Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Facility Phone

(###)

###

####

Facility Fax

(###)

###

####

SNF Beds

Yes

AL Beds

Yes

SL Beds

Yes

Admin/Manager

First Name

Last Name

Admin Email

DON/NC: Name

First Name

Last Name

DON/NC: Email

SW/SS: Name

First Name

Last Name

SW/SS: Email

Dietary: Name

First Name

Last Name

Dietary: Email

Activity: Name

First Name

Last Name

Activity: Email

Corporation Name

Corporation: Email

Profit or Non-Profit

Multi-Facility or Independent

Website

http://

PAC Donation

Do you wish to make a donation to PAC? ($%.00 per bed)(Will be invoiced spearately from dues.)

Yes

Accounts Payable

First Name

Last Name

Accounts Payable Email

Number of Beds / Units

Based on SD DEPT of HEALTH RECORDS

Licensed Nursing Facility Beds

Licensed Assisted Living Beds

Senior Living Beds

YOUR TOTAL NUMBER OF BEDS

Agreement

Please complete the information portion of this agreement, sign at the bottom, and return it to the SDHCA/SDALA. Signing indicates that you agree to pay all membership dues applicable to your facility based on the total number of your licensed beds for year 2024-25. I understand that by providing my mailing address, e-mail address, telephone number, and FAX number, I consent to receive communications sent by or on behalf of the South Dakota Health Care Association, and its respective affiliates, via mail, e-mail, telephone, or FAX. I also consent to an electronic signature in place of a handwritten signature on this document by placing my initials below.

Authorized Signature

Typed name will act as signature

First Name

Last Name

Title

Todays Date

YYYY