	Associate Care Center

1.

Organization & Primary Contact Information:*

Organization/Company:
Address:
City, State, Zip:
Phone:
Fax:
Website:
Primary Contact First & Last Name:
Primary Contact Title:
Primary Contact Phone:
Primary Contact Email:

2.

Type of Ownership*

	Proprietary
	Proprietary - privately owned
	Proprietary - publicly traded
	S-Corporation

3.

If you have a parent corporation/owner other than that listed above, please provide the following:

Parent Organization Name:
Address:
City, State, Zip:
Phone:
Fax:
Website:
Contact Name, Title & Email:

4.

If you have a management company other than that listed above, please provide the following:

Parent Organization Name:
Address:
City, State, Zip:
Phone:
Fax:
Website:
Contact Name, Title & Email:

5.

Other Contacts from Your Organization

Dues Contact Name (if different from primary):
Dues Contact Title:
Dues Contact Email:

6.

Please list any other team members you wish to receive communications from LeadingAge Minnesota:

Name:
Title:
Email:
Name:
Title:
Email:

7.

About the Building:
*

Total Number of Licensed Care Center Beds

8.

Of the total number of active beds, please indicate how many are designed for:*

Board & Care Certified
Board & Care Non-Certified
Transitional Care
Dementia Care
Other Non-designated Specialty Care

10.	Do you an adult day program in your building?
	YesNo

11.

Is your adult day program licensed?

	No - unlicensed, under 5 people served
	Yes

If licensed, enter the capacity for this program:

12.	Electronic Signature* (Please type in your name)

This category of membership provides full member benefits, excluding the ability to vote, hold office or serve as a Director. A LeadingAge Minnesota membership is needed for each building. For prospective members that are part of a multi-building organization, all eligible buildings of that organization shall be members of LeadingAge Minnesota.

Please submit dues to:

LeadingAge Minnesota
3001 Broadway Street NE, Suite 300
Minneapolis, MN 55413
651.645.0002 (FAX)
membership@leadingagemn.org