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Kansas Health Care Association

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Advancing Excellence in America's Nursing Homes

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Membership Application

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Please submit the following information. (Items with a red square are required.) If you have additional questions, please contact us at (785) 267-6003.

Membership Type (Required)

Regular Associate

Contact Person

First Name (Required)

M.I.

Last Name (Required)

*Facility/Company/Organization

*Facility/Company/Organization (Required)

Street (Required)

State (Required)

Zip (Required)

phone (Required)

Fax

Email (Required)

Main Product or Service (Required)

Administrator

DON

Number of Licensed Beds/Units

Additional Comments