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Participants

The Puget Sound Health Alliance is directed and funded by the private, public and non-profit organizations and individuals who join the Alliance. To join, complete this form and you will be contacted by Alliance staff to give you additional information, including the annual fee to become a participant.

My Organization If you do not represent an organization, please check the box below and complete only the “My Information” portion of this form.
	I do not represent any organization.
Organization Name*:
Primary Contact Email*:
Address 1*:
Address 2:
City*:
State*:	AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT
Zip Code*:
Phone*:
Fax*:
How many of the following does your organization have in the five-county region of King, Kitsap, Pierce, Snohomish and Thurston:
	a. Total number of insured/covered lives (statewide): b. Total number of fulltime/part-time employees in 5-county area: c. Number of FTEs (full-time equivalents) in 5-county area: d. Number of covered lives for your employees (in 5-county area): (i.e., total number of employees, spouses and other dependents for whom your organization provides health insurance coverage)
Does the Alliance have permission to list your organization's name in our materials?*
	Yes   No
If you would like the Alliance to link to your organization's website in the list of participating organizations, provide your organization's website:
What additional information should the Alliance know about your organization?
My Information
First Name*:
Last Name*:
Address 1*:
Address 2:
City*:
State*:	AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT
Zip Code*:
Title/Position*:
Phone*:
Cell Phone:
Fax:
Email Address*:
Does the Alliance have permission to list your name in our materials?*
	Yes   No
How would you like to be involved in the Alliance? Please list any areas of interest or expertise:
What additional information should the Alliance know about you?

Fields marked with * are required