2017 DAHCC Membership Application Form

DAHCC membership is open to all providers of home and community based services based upon the following levels of membership.

Agency Membership (for agencies with the following levels of licensure: 4406 Aide only, 4410 Skilled, 4469 PASA, and 4468 Hospice)

  1. Bronze membership- Startup agency with annual revenue < 1 million $200
  2. Silver membership- Organization with annual revenue 1-3 million $400
  3. Gold membership- Organization with annual revenue >3 million $600

Agency membership entitles an agency to:

  1. Membership on the Advisory Board and participation in its activities.
  2. A vote in DAHCC activities.
  3. Appointment of an individual staff memberto represent the agency on the Board, although more than one member may attend and participate.
  4. The right to display the DAHCC membership logo.
  5. Inclusion in list of DAHCC agency memberships on the website.
  6. Unlimited attendees to general membership meetings.

Associate Membership$100

  1. An associate membership is available for non-agency or providers who are not licensed as listed above, but wish to attend general membership meetings.
  2. These members would not be eligible to participate in Advisory Board activities unless invited for a special purpose.
  3. Inclusion in list of DAHCC associate memberships on the website.

Please complete the information on the second page of this form to apply and enclose your check made out to:

Delaware Association for Home and Community Care

c/o PO Box 7603

Wilmington DE 19803

Please return by January 31, 2017

DAHCC APPLICATION

Membership type (Please check)

Agency: Gold ______Silver ______Bronze ______

Associate ______

Contact information:

Name: ______

Address: ______

______

Phone:______

E-mail:______

The following information is required for Agency members only:

Contact information for Agency Representative:

Name/Title of Agency Representative: ______

Phone: ______

E-mail: ______

Alternate Agency Representative: (optional)

Name:______

Phone:______

E-mail:______

Signature of person authorized to sign for agency

Signature: ______Date: ______

Print name: ______