CJFHC Membership Application Form

General Membership Application Form
Name of Applicant/Organization(*)
Please type your full name or the name of your organization.

Contact Person
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Title
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Address 1(*)
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Address 2
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City, State Zip(*)
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Telephone(*)
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Fax
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E-mail(*)
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Membership type?(*)

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*A Non-Hospital Provider General Member includes(licensed Ambulatory Care Facilities, professional organizations, nonprofit organizations, local/county governmental agencies, or any other organization concerned with the needs of families with infants, children and adolescents, including those with special health care needs).
*A Consumer General Member includes community and consumer organizations and/or individuals.

Additional Information

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Principal reason for Membership request:
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I would be interested in serving on one of the following committees (All committees have specific requirements that must be met which will be taken into consideration.)

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CQI consists of a chair & a co-chair, representatives of each category of Trustee, and other individuals as appointed from among the Trustees &/or other community representatives/agencies. CQI is responsible for performing all quality assurance, clinical review, education & planning functions of the Consortium. The committee meets as often as deemed necessary but at least annually.

ICRT is a group of healthcare professionals that meets 6 times a year. A subcommittee of CQI, ICRT is made up of Trustees &/or other individuals/agencies. Medical chart audits of selected cases & de-identified summaries involving maternal mortality, selected pediatric deaths, women delivering after receiving no prenatal care, non-compliance with rules regarding birth weight & gestational age, neonatal transports w/death & fetal deaths >2500 gms, and infant deaths are reviewed by the team & make recommendations on how the region can improve care.

Resume or CV Upload
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(*)

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