Membership Application


QUALIFYING INFORMATION

A. I attest that this clinic/charitable care organization is (please check all that apply):

 
 

 
 


B.  

Free Clinic: a nonprofit organization that provides direct healthcare services at little of no cost to the underserved/indigent population of Washington through the use of volunteer health professionals, community volunteers, and partnerships with other healthcare providers.

Charitable Care Organization: a nonprofit organization that provides, coordinates or supports healthcare access for underserved/indigent communities.

Associate memberships are available for organizations that do not meet the criteria listed above and for individuals who wish to join the WHAA.

Annual Dues




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Mailing Address, Phone, Email, and Website









Services Provided

 
 
 
 
 
 
 
 






DESIGNATED REPRESENTATIVE INFORMATION

Please designate a representative with whom WHAA can communicate important updates and membership notifications.