Associate Membership Personal InformationPersonal Name(Required) First Last Personal Email(Required) Enter Email Confirm Email Personal Phone(Required)Personal Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Professional InformationOrganization Name(Required)The name of your organization is displayed in your profile.Organization Website(Required)The organization website will be displayed in your profile. Organization Address(Required)The organization address of your organization is displayed in your profile. Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Organization Phone(Required)The organization phone of your organization is displayed in your profile. Organization FaxThe organization fax of your organization is displayed in your profile.Number of Patients Admitted last calendar year?(Required)(Not visible in profile)Volunteer Hospice(Required)(Not visible in profile) Yes No “Stand Alone” Palliative Care Programs(not affiliated with a hospice program) | (Not visible in profile) Yes No Rural palliative care program?(Not visible in profile) Yes No Counties Served(Required)AdamsAsotinBentonChelanClallamClarkColumbiaCowlitzDouglasFerryFranklinGarfieldGrantGrays HarborIslandJeffersonKingKitsapKittitasKlickitatLewisLincolnMasonOkanoganPacificPend OreillePierceSan JuanSkagitSkamaniaSnohomishSpokaneStevensThurstonWahkiakumWalla WallaWhatcomWhitmanYakimaCounties served will be displayed in your profile.Cities Served(Required)AberdeenAirway HeightsAlbionAlgonaAlmiraAnacortesArlingtonAsotinAuburnBainbridge IslandBattle GroundBeaux Arts VillageBellevueBellinghamBenton CityBingenBlack DiamondBlaineBonney LakeBothellBremertonBrewsterBridgeportBrierBuckleyBucodaBurienBurlingtonCamasCarbonadoCarnationCashmereCastle RockCathlametCentraliaChehalisChelanCheneyChewelahClarkstonCle ElumClyde HillColfaxCollege PlaceColtonColvilleConconullyConcreteConnellCosmopolisCoulee CityCoulee DamCoupevilleCovingtonCrestonCusickDarringtonDavenportDaytonDeer ParkDes MoinesDuPontDuvallEast WenatcheeEatonvilleEdgewoodEdmondsElectric CityEllensburgElmaElmer CityEndicottEntiatEnumclawEphrataEverettEversonFairfieldFarmingtonFederal WayFerndaleFifeFircrestForksFriday HarborGarfieldGeorgeGig HarborGold BarGoldendaleGrand CouleeGrandviewGrangerGranite FallsHamiltonHarrahHarringtonHartlineHattonHoquiamHunts PointIlwacoIndexIoneIssaquahKahlotusKalamaKelsoKenmoreKennewickKentKettle FallsKirklandKittitasKruppLa CenterLa ConnerLaceyLaCrosseLake Forest ParkLake StevensLakewoodLamontLangleyLatahLeavenworthLiberty LakeLindLong BeachLongviewLymanLyndenLynnwoodMabtonMaldenMansfieldMaple ValleyMarcusMarysvilleMattawaMcClearyMedical LakeMedinaMercer IslandMesaMetalineMetaline FallsMill CreekMillwoodMiltonMonroeMontesanoMortonMoses LakeMossyrockMount VernonMountlake TerraceMoxeeMukilteoNachesNapavineNespelemNewcastleNewportNooksackNormandy ParkNorth BendNorth BonnevilleNorthportOak HarborOakesdaleOakvilleOcean ShoresOdessaOkanoganOlympiaOmakOrovilleOrtingOthelloPacificPalousePascoPaterosPe EllPomeroyPort AngelesPort OrchardPort TownsendPoulsboPrescottProsserPullmanPuyallupQuincyRainierRaymondReardanRedmondRentonRepublicRichlandRidgefieldRitzvilleRiversideRock IslandRockfordRosaliaRoslynRoyRoyal CityRustonSammamishSeaTacSeattleSedro-WoolleySelahSequimSheltonShorelineSkykomishSnohomishSnoqualmieSoap LakeSouth BendSouth Cle ElumSouth PrairieSpangleSpokaneSpokane ValleySpragueSpringdaleSt. JohnStanwoodStarbuckSteilacoomStevensonSultanSumasSumnerSunnysideTacomaTekoaTeninoTietonToledoTonasketToppenishTukwilaTumwaterTwispUnion GapUniontownUniversity PlaceVaderVancouverWaitsburgWalla WallaWapatoWardenWashougalWashtucnaWatervilleWaverlyWenatcheeWest RichlandWestportWhite SalmonWilburWilkesonWilson CreekWinlockWinthropWoodinvilleWoodlandWoodwayYacoltYakimaYarrow PointYelmZillahCities served will be displayed in your profile.Please check all the services your program provides(Required)Services provided will be displayed in your profile. Hospice Inpatient Hospice Palliative Care Inpatient Palliative Care Inpatient Palliative Care Select AllDistribution List interest?(Not visible in profile) QAPI/Regulatory Networking Group Public Policy Networking Group Education/Conference Planning Group Medical Directors, Physicians, NPs Networking Group Palliative Care Networking Interest Group PR/Marketing/Development Networking Group Volunteer Coordinators Networking Group Billers Networking Interest Group Pediatric Palliative Care Networking Interest Group Staff Role?(Required)Staff role will be displayed in your profile. Bereavement Coordinator Board Member Clinical Contact Group Contact Medical Director PR/Marketing/Development Coordinator Primary Contact QAPI/Regulatory Coordinator Spiritual Care Coordinator Social Worker Volunteer Coordinator Create Provider MembershipUsername(Required)Provider Membership UsernameAssociate Membership Email(Required)Email used to log into wshpco.org Enter Email Confirm Email Associate Membership Password(Required) Enter Password Confirm Password Strength indicator Set a password to log into your wshpco.org Associate Membership Account. Membership & TotalAssociate Membership Dues:(Required) Price: $500 annually.Total
