Individual Hospital

Fields marked by * are mandatory.

Individual Hospital

New Member Application Form

* Hospital 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:

Number of Employees

*Please select any one of the options:

1,000<5,000

5,000<10,000

10,000<20,000

20,000<50,000

Over 50,000

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 No
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.

Individual Hospital

New Member Application Form

*Please check all that apply:

*Please select any one of the options:

*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.