CT HCC Membership Agreement

The Connecticut Health Care Coalition (CT HCC) is an interconnected partnership among key stakeholders whose mutual goal is to promote disaster resilience within the Connecticut health care delivery workforce. CT HCC seeks to prepare for and respond to mass-casualty and catastrophic medical and public health incidents that elicit a large and sudden influx of patients to hospitals, and potentially, interrupt essential functions of the healthcare delivery system. The mission of the CT HCC is to promote collaboration, education, and joint exercises during the planning and preparedness phases of emergency management. During real-world operations, the mission of the CT HCC is to help identify resources at the state and sub-state levels, and to collect, analyze, validate, and disseminate essential elements of information to partner agencies.

An organization shall be considered an official Coalition member organization after signing and submitting a member agreement form. The agreement is not legally binding and is a good-faith agreement that CT HCC member organizations will support and integrate within existing health and medical response and recovery activities within the parameters of statutory authority, jurisdictional and/or organizational Emergency Operations Plans and as defined within the principles of emergency management.

Coalition membership is open to any entity that provides or supports health services in the State of Connecticut. For more information about which kinds of organizations can join the CT HCC, please refer to the CT HCC Bylaws.

Organizations that have attended at least two regularly scheduled CT HCC meetings within a 12-month period are now eligible to obtain the "Active Member" designation, and therefore will be eligible to be Voting Members. Upon submission of this form, CT HCC staff will contact you to confirm your status as an Active (Voting) Member if your organization is eligible.

By signing the agreement, Coalition member organizations agree to:

Provide representation at Coalition meetings
Participate in Coalition activities and help to ensure the coalition can meet its identified goals, priorities, and contractual deliverables
Participate in collaborative preparedness planning efforts
Participate in the development of surge capacity plans, inter-organizational agreements, and collaborative emergency response plans
Vote on coalition activities and elections
Respond, as able, to emergencies and disasters in collaboration with other Coalition members
Work to implement emergency preparedness and response capability guidelines within the member’s organization
Update all applicable information sharing/resource coordination platforms (e.g. ProtectAdvisr™, WebEOC, LTC MAP)

Member Organization Information

Please provide some information about your organization for our records.

Organization Name

Organization Type

Organization Street Address

Organization Street Address Line 2

Organization Address City

Organization Address State

Organization Address Zip Code

Mailing Address is different than Physical Address

Check this box if your organization's mailing address differs from the physical address.

Organization Representatives

Please notify the CT HCC of two representatives (primary and secondary) designated to cast a vote in Full Coalition meetings for the organization. Please note that if your organization is represented on the coalition's Executive Committee, your secondary representative cannot vote in Executive Committee meetings.

Applicant Full Name

Applicant Job Title

Applicant Email

Applicant Phone Number

Phone

Secondary Representative Full Name

Secondary Representative Job Title

Secondary Representative Email

Secondary Representative Phone Number

Phone

Signature

Please type your full name below to agree to the membership agreement terms. This can be the name of any individual associated with your organization who is authorized to sign such agreements.

Authorized Representative's Full Name

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