Health Care Regions Membership Application – Canadian Coalition for Green Health Care

This is the membership application for Health Care Region memberships. If you are applying as an individual or on behalf of a non-profit or individual health care organisation, please go back and select the appropriate application.

If you have any difficulty completing the form or any questions about the membership application process, please contact robert@greenhealthcare.ca

New Membership

Membership *

Health Regions - $ 500.00

Total Amount

On Behalf Of Health Care Organisation

Organisation Name *

Email *

Street Address *

City *

Postal Code *

Country *

Province/Territory *

Total Number of Staff *

Number of persons employed (head counts), and number of full-time equivalent (FTE) persons employed in general and specialty hospitals. Self-employed are included.

Number of Sites in the Organisation *

Number of separate hospital and other care sites.

Health Care Details

Number of Hospital Beds *

Number of Long Term Care Beds *

Number of Residential Care Beds *

Please enter a Username to create an account. If you already have an account please login before completing this form.

Username *

Check Availability
Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores.

Password

Confirm Password

Provide a password for the new account in both fields.

Primary Contact

First Name *

Last Name *

Job Title *

Email *

Phone and Extension