Healthcare Membership Inquiry Form

I have reviewed the information about Schwartz Center membership and the Schwartz Center Rounds® program on this website and I am interested in learning more. All inquiries will receive a response within two weeks. * indicates required field

Name of Person to Contact*
First Last Suffix
Job Title*
Email Address*
Enter Email Confirm Email
Name of Hospital/Healthcare Institution*
Organization Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Website*
Phone*
Phone Extension
How do you classify your healthcare institution?*
Hospital Type
Long-Term Facility Type
Outpatient Facility Type
Other Type
If other, please specify:*
Is your institution a member of the Greater New York Hospital Association?*
- Yes
- No
- Not Sure
How did you hear about the Schwartz Center?*
Name of conference*
Name of Schwartz Center Event*
Colleague*
- Works within my organization
- Works at another organization
If other, please specify*
Additional Comments