Registration Join the Chicago Coalition Scroll Down Member Registration First Name * Last Name * Role * Emergency Department (Manager/Director/Medical Director) EMS (Provider/Coordinator) Emergency Preparedness/Liaison Officer Infection Control Information Technology/Cybersecurity Pharmacy Security Trauma Coordinator Radio/Communication Title Work Email * Confirm Work Email * Confirm Email Password * Confirm Password * Confirm Password Office Phone Mobile Phone Are you the primary person responsible for emergency preparedness at your organization? * Yes No Does your organization serve the city of Chicago? * Yes No * Organization Address * City * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Facility Type Ambulatory Surgical Center (ASC) End-Stage Renal Disease (ESRD) Facility Federally Qualified Health Center Home Health Agency (HHA) Hospice Hospital Hospital - Acute Care Hospital - Pediatric Hospital - Rehabilitation Facility Hospital - Veterans Hospital - Psychiatric Governmental Agency Long Term Care (LTC) Facility Organ Procurement Organization (OPO) Outpatient Rehabilitation Facility Private Ambulance Provider Psychiatric Residential Treatment Facility (PRTF) Religious Nonmedical Health Care Institution (RNHCI) Skilled Nursing Facility Transplant Center Other Are you requesting access to EMResource? Access is limited to hospitals, dialysis centers, long-term care facilities. * Yes No Do you have interest in joining any Coalition Committees? * More Info Yes No Please check all that apply. Additional Healthcare Partners Information Sharing Medical Surge Responder Health and Safety Training and Exercise Subscribe I would like to receive CHSCPR communications reCAPTCHA If you are human, leave this field blank. Become A Member
