Hospital System

Hospital System

Fields marked by * are mandatory.

New Member Application Form

* Hospital System Name:

Main Location Address: * Address 1:

Address 2:

* City:

* State:

* Zip Code:

* Phone :

Contact Information

* Primary Contact Name:

Title:

Mailing address: * Address 1:

Address 2:

* City:

* State:

* Zip Code:

* Phone:

* Email:

Secondary Contact Name:

Title:

Mailing address: Address 1:

Address 2:

City:

State:

Zip Code:

Phone:

Email:

Hospital Specialty

* Please indicate the number of specialty hospitals within your system.

Acute Care

Children’s

Rehab

Psych

Cancer

Orthopedic

Skilled Nursing Facility/Long Term Care

Women’s

Critical Access

Other :

Hospital Type(s)

*Please check all that apply:

For Profit

Not for Profit

Government

Teaching

Academic

Community

Faith Based

Employee Survey

Date of last Employee Survey

(mm/dd/yyyy)

Frequency:

Annually

Every 2 to 3 years

Never

No set frequency

Other Memberships

*Are you a member of ASHHRA?

Yes Since

What other Healthcare Organization memberships do you hold?

Areas of Interest

Topics you would like to learn about.

Topics you might like to share with a group.

Payment Information

Initial membership cost is $250.00. This amount includes your application fee and complimentary first year dues.
Dues after the first year will be determined.

Credit

Please call The Foresight Group at 800-252-6150, ext. 230.

Check

Please send a check payable to Lightspeed Research - The Foresight Group in the amount of $250.00, and mail to:

Lightspeed Research - The Foresight Group
65 Oakwood Road
Lake Zurich, IL 60047

Questions? Please call (847) 726 - 4040.

Hospital System

New Member Application Form

* Please indicate the number of specialty hospitals within your system.

*Please check all that apply:

Date of last Employee Survey

Frequency:

*Are you a member of ASHHRA?

What other Healthcare Organization memberships do you hold?

What accreditations/awards does your hospital hold?

Topics you would like to learn about.

Topics you might like to share with a group.