VCHA, Inc. 2017 Membership Application
Ventura County Homecare Association, Inc.
Due by January 15, 2017

The VCHA purpose is to promote:
• Homecare as an essential component of the health care delivery system.
• An educational/support network for homecare providers.
• Advocacy for patient rights to quality coordinated healthcare.
• Encouragement through collegiate pride as we provide patient care with dignity.

Membership in the VCHA includes individuals or organizations involved in the provision or facilitation of services and/or care to a patient/client in their home setting.

A $25.00 late fee will apply to all applications received after January 15, 2017

Additional charges for guest of member: $30.00/person/meeting.

PLEASE SUBMIT ONE FORM PER MEMBER

Email address
DUES
Annual Membership dues include:
• Six lunches and featured presentation for one company representative per year
• One vote per company
• Contact Hour(s) as applicable for Continuing Education Units
• Listing in the VCHA website directory in one category
Membership is dependent upon the successful completion of the application process.
MEMBERSHIPS/MEMBERS
Membership shall be recognized through one's Umbrella Organization, which is defined as an individual, parent corporation, or entity, which may or may not have separate and unique divisions denoted with their own tax identification numbers. Each Umbrella Organization shall be allowed two memberships known as Active Membership. Each active membership will be listed in ONLY ONE SERVICE CATEGORY.

Active Members are required to serve on a VCHA committee.

Additional Active Members: Each Umbrella Organization shall be allowed additional members under the same company/category. There is no limit to the number of Additional Active Members. However, these individuals will not be eligible to hold office in the association and must participate in a VCHA committee.

Non-Active Members are not required to serve on a VCHA committee.

Type of Memberships/Members
Please choose one
Active Members are required to serve on a committee. Please check your committee preference:
If you would like the VCHA to select a committee for you, leave this section blank.
Note: Applying NEW members must fill out New Member section
First Name:
Your answer
Last Name:
Your answer
Title:
Your answer
Email:
Your answer
Company Name:
Your answer
Company Website:
Your answer
Company Street Address (include box, room or suite number):
Your answer
Company City:
Your answer
Company Zip Code:
Your answer
Company Phone:
Your answer
Company Fax:
Your answer
Company Number of Employees:
Your answer
Accreditations/Licenses:
Your answer
License Number(s):
Your answer
Affiliations:
Your answer
Company Category
Choose one only
NEW MEMBER
How did you find out about VCHA?
If a VCHA Member referred you, who was it?
Your answer
Purpose for joining VCHA:
Choose as many as apply
Company References
Please list the names and phone numbers of two professional references, this is required for membership consideration.
Your answer
VCHA Code of Ethics
Purpose: The purpose of the Code of Ethics of the Ventura County Homecare Association, Inc. (VCHA) is to serve as a guide for the conduct of its members. It contains standards of ethical behavior for members in their professional relationships.

Mission: The mission of the VCHA is to enhance the effectiveness of the home care delivery community through professional education, legislative advocacy, peer networking and support systems as we endeavor to provide optimum services to those entrusted in our care.

Preface: The Code of Ethics is developed and upheld by the Executive Board, which is comprised of active members of the VCHA.

Procedure: The Executive Board will review potential violations of The Code of Ethics and respond appropriately.

As a member, I agree to the following:
1. Conduct all business activities with honesty, integrity, respect, fairness and good faith in a professional manner that will reflect well upon the VCHA.
2. Comply with Federal, State, Local, and Accreditation regulatory bodies as it pertains to the service(s) provided.
3. Maintain professional competencies relevant to certification, licensure, and/or service(s) provided.
4. Respect professional confidences and proprietary information.
5. Promote actions that build a positive image of the VCHA.
6. Represent accurately services and products available through each member’s business/organization.
7. Compete honorably.
8. Ensure the confidentiality of legally protected information.
9. Promote positive working relationships with VCHA members in a non-discriminatory manner.
Electronic Signature (enter initials)
My electronic signature indicates understanding and agreement with the above Code of Ethics.
Your answer
Required for Membership
NEW MEMBER, please mail:
• Copy of any required Federal, State or City License
• Certificate of Insurance
• Company Brochure

NEW OR RENEWING NON-MEDICAL HOME CARE COMPANIES ONLY: Both New and Renewing Non-Medical Home Care company memberships must submit the following:
• Current CAHSAH certification
OR
• Signed VCHA certification stating that caregivers employed by the company are screened and background checked. You may print a VCHA certification form here: http://vchainc.org/wp-content/uploads/2015/10/VCHA_Home-Care-Certification-2016_10215vA.pdf

PLUS
• Proof of general liability insurance
• Proof of Workers' Comp insurance

Payment
Payment may be made online via the PayPal "Donate" button on the VCHA website: http://vchainc.org/membership/

Submit this membership application online. Please mail designated collateral to:
Mission Home Health
Attn: Amanda Larson (Membership Chair)
1957 EAstman Ave., Suite A-1
Ventura, CA 93003
Phone: 805-535-8706

Ventura County Homecare Association, Inc. is a 501(c)3 non-profit organization, Tax ID #20-0293626
VCHA, Inc.
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