Name of Clinic/Organization
QUALIFYING INFORMATION
A. I attest that this clinic/charitable care organization is (please check all that apply):
A nonprofit organization with 501(c)3 tax-exempt status A program of a larger nonprofit organization Name of parent organization A start-up organization that plans to file for 501(c)3 nonprofit status An individual or business wishing to support the Washington Healthcare Access Alliance
B. I attest that this clinic/organization meets the criteria of a Free Clinic or Charitable Care Organization.
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 Associate Organization: $500 Associate Individual: $50 Free Clinic and Charitable Care Organization
Select Payment Method Pay with credit/debit card. Please send an invoice.
This organization is not yet serving patients.
DESIGNATED REPRESENTATIVE INFORMATION
Please designate a representative with whom WHAA can communicate important updates and membership notifications.
Name
Title
Phone
Email
Submit
