CTHCA 2012 MEMBERSHIP FORM Annual Membership Dues $250
MEMBERSHIP: NEW: RENEWAL: CLASSIFICATION: AGENCY: INDIVIDUAL:
DATE:
AGENCY/COMPANY NAME: DCP REGISTRATION #
CONTACT PERSON:
PRIMARY ADDRESS: SECONDARY ADDRESS: CITY: STATE: ZIP: TELEPHONE: FAX: TOLL FREE NUMBER: EMERGENCY PHONE: ANSWERING SERVICE FOR 24-HOUR AVAILABILITY: YES NO DOES YOUR AGENCY HAVE SATELLITE OR ADDITIONAL LOCATIONS? YES NO (If "YES," please list them in SECTION B) EMAIL ADDRESS: WEB ADDRESS: TYPE OF AGENCY HOMEMAKER/COMPANION: OTHER (PLEASE SPECIFY BELOW): NON-PROFIT: YES NO YEAR BUSINESS OPENED REGULAR OFFICE HOURS: (PLEASE NOTE DAYS AND HOURS OF OPERATION) WHAT SERVICES DOES YOUR AGENCY PROVIDE?  (PLEASE HOLD THE CONTROL BUTTON FOR MULTIPLE SELECTIONS) HOMEMAKER DAY COMPANION LIVE-IN COMPANION OVERNIGHT COMPANION TRAVEL COMPANION SPECIALTY CARE FINANCIAL ASSISTANCE PERSONAL CARE SERVICES ALZHEIMER'S CARE COMPANION SPECIAL EVENTS ASSISTANCE PERSONAL EMERGENCY RESPONSE SYSTEM OTHER OTHER (PLEASE SPECIFY) CLIENT POPULATION SERVED: (PLEASE HOLD THE CONTROL BUTTON FOR MULTIPLE SELECTIONS) ELDERLY ELDERLY ALZHEIMER ADULT PHYSICALLY DISABLED CHILD/ADOLESCENT PHYSICALLY DISABLED MENTALLY CHALLENGED OTHER OTHER (PLEASE SPECIFY) SERVICE AREA FOR PRIMARY AGENCY ADDRESS: Please refer to Section B and select all town you serve by county.  Please hold the control button for multiple selections.
Would you like your agency to be listed in our directory? YES NO Would you like all satellite locations listed? YES NO Would you be interested in serving on one of our committees?  (Please hold the control button to make a selection) Education Legislative Membership What issues/topics would you like to see CTHCA address either by training/seminar or at the legislative level?
SECTION B:  Service Area Towns Served by County   (PLEASE HOLD THE CONTROL BUTTON FOR MULTIPLE SELECTIONS) FAIRFIELD COUNTY BETHEL BRIDGEPORT BROOKFIELD DANBURY DARIEN EASTON FAIRFIELD GREENWICH MONROE NEW CANAAN NEW FAIRFIELD NEWTOWN NORWALK SHELTON SHERMAN STAMFORD STRATFORD REDDING RIDGEFIELD TRUMBULL WESTON WESTPORT WILTON HARTFORD COUNTY AVON BERLIN BLOOMFIELD BRISTOL BURLINGTON CANTON EAST GRANBY EAST HARTFORD EAST WINDSOR ENFIELD FARMINGTON GLASTONBURY GRANBY HARTFORD HARTLAND MANCHESTER MARLBOROUGH NEW BRITAIN NEWINGTON PLAINVILLE ROCKY HILL SIMSBURY SOUTHINGTON SOUTH WINDSOR SUFFIELD WEST HARTFORD WETHERSFIELD WINDSOR WINDSOR LOCKS LITCHFIELD COUNTY BARKHAMSTED BETHLEHEM BRIDGEWATER CANAAN COLEBROOK CORNWALL GOSHEN HARWINTON KENT LITCHFIELD MORRIS NEW HARTFORD NEW MILFORD NORFOLK NORTH CANAAN PLYMOUTH ROXBURY SALISBURY SHARON THOMASTON TORRINGTON WARREN WASHINGTON WATERTOWN WINCHESTER WOODBURY MIDDLESEX COUNTY CHESTER CLINTON CROMWELL DEEP RIVER DURHAM EAST HADDAM EAST HAMPTON ESSEX HADDAM KILLINGWORTH MIDDLEFIELD MIDDLETOWN OLD SAYBROOK PORTLAND WESTBROOK NEW HAVEN COUNTY ANSONIA BEACON FALLS BETHANY BRANFORD CHESHIRE DERBY EAST HAVEN GUILFORD HAMDEN MADISON MERIDEN MIDDLEBURY MILFORD NAUGATUCK NEW HAVEN NORTH BRANFORD NORTH HAVEN ORANGE OXFORD PROSPECT SEYMOUR SOUTHBURY WALLINGFORD WATERBURY WEST HAVEN WOLCOTT WOODBRIDGE NEW LONDON COUNTY BOZRAH COLCHESTER EAST LYME FRANKLIN GRISWOLD GROTON LEBANON LEDYARD LISBON LYME MONTVILLE NEW LONDON NORTH STONINGTON NORWICH OLD LYME PRESTON SALEM SPRAGUE STONINGTON VOLUNTOWN WATERFORD TOLLAND COUNTY ANDOVER BOLTON COLUMBIA COVENTRY ELLINGTON HEBRON MANSFIELD SOMERS STAFFORD TOLLAND UNION VERNON WILLINGTON WINDHAM COUNTY ASHFORD BROOKLYN CANTERBURY CHAPLIN EASTFORD HAMPTON KILLINGLY PLAINFIELD POMFRET PUTNAM SCOTLAND STERLING THOMPSON WINDHAM WOODSTOCK Please list the name, address and telephone number of any satellite offices you would like us to include in your survey. Thank you for your membership application and survey responses.  CTHCA requires that you review the association rules and by-laws and pledge to abide by them and conduct yourself and your business in an ethical manner.  I have read the rules and by-laws of CTHCA and pledge to abide:    I AGREE I DISAGREE NAME: DATE: An annual membership fee of $250 must accompany this application.  Please submit your application via the web site and forward your payment separately. Checks are payable to: CTHCA, PO Box 210898, Newington, CT 06111