Membership Application

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=160 BGCOLOR="#006699" TEXT="#080000" background="16d00a03.jpg"> <div> <I><B>V</B></I><FONT SIZE="6" COLOR="#000080" FACE="Verdana" ><I><B>oices</B></I></FONT><FONT SIZE="6" COLOR="#000080" FACE="TimesRoman" ><I><B> </B></I></FONT><FONT SIZE="5" COLOR="#000080" FACE="Verdana" ><I><B>for Quality Care (LTC), Inc.</B></I></FONT></div> <bR> <div> <B>P.O. Box 2251, Leonardtown, MD 20650</B></div> <div> <B>1-888-600-2375</B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="178cae83.jpg"> <div> <B> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="177" BORDERCOLORLIGHT="#000099" BORDERCOLORDARK="#000099" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 640 WIDTH="165"><div> <B>Website Navigation Panel</B></div> <div> Click on the text below to go to other pages in our website<FONT SIZE="2" COLOR="#000000" FACE="Arial" ><B>.</B></FONT></div> <div> <A HREF="index.htm" TARGET="_top" TITLE="Voices for Quality Care"><U><B>Home</B></U></A></div> <div> <A HREF="id45.htm" TARGET="_top" TITLE="About Voices"><U><B>About Voices</B></U></A></div> <div> <A HREF="id59.htm" TARGET="_top" TITLE="Culture Change"><U><B>Culture Change</B></U></A></div> <div> <A HREF="id72.htm" TARGET="_top" TITLE="Beth Bakers Book"><U><B>Beth Baker's Book</B></U></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="Nursing Home Staffing in Maryland"><U><B>Nursing Home Staffing in Maryland</B></U></A></div> <div> <A HREF="id48.htm" TARGET="_top" TITLE="Washington,DC Nursing Home Data"><U><B>Washington, DC Nursing Home Data</B></U></A></div> <div> <A HREF="id180.htm" TARGET="_top" TITLE="Star Ratings"><U><B>Nursing Home Star Ratings</B></U></A></div> <div> <A HREF="id56.htm" TARGET="_top" TITLE="Laws and Regulations"><U><B>Laws and Regulations</B></U></A></div> <div> <A HREF="id47.htm" TARGET="_top" TITLE="Related Websites"><U><B>Related Websites</B></U></A></div> <div> <A HREF="id43.htm" TARGET="_top" TITLE="Contact Us"><U><B>Contact Us</B></U></A></div> <div> <A HREF="id46.htm" TARGET="_top" TITLE="Membership Application"><U><B>Membership Application</B></U></A></div> <div> <A HREF="id53.htm" TARGET="_top" TITLE="Directions to Our Meetings"><U><B>Directions to Our Meetings</B></U></A></div> <div> <A HREF="id52.htm" TARGET="_top" TITLE="Voices ByLaws"><U><B>Voices ByLaws</B></U></A></div> <div> <A HREF="id54.htm" TARGET="_top" TITLE="Terms of Service"><U><B>Terms of Service</B></U></A></div> <div> <A HREF="id55.htm" TARGET="_top" TITLE="Privacy Policy"><U><B>Privacy Policy</B></U></A></div> <div> <A HREF="id176.htm" TARGET="_top" TITLE="Maryland Ombudsman Program"><U><B>MD Ombudman Program</B></U></A></div> <div> <A HREF="id178.htm" TARGET="_top" TITLE="Assisted Living Choices"><U><B>Assisted Living Choices</B></U></A></div> <div> <A HREF="id181.htm" TARGET="_top" TITLE="FamilyCouncil"><U><B>Family Councils</B></U></A></div> <div> <A HREF="id76.htm" TARGET="_top" TITLE="Donation"><U><B>Donate to Voices</B></U></A></div> </tD> </tR> </TABLE></B></div> <bR> </td> <td valign="top" height=320 BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> <div>  <html> <head> <title>Membership Application</title> <meta name="generator" content="Created Using Yahoo! PageBuilder 2.61.90"> </head> <body bgcolor="#CCFFFF" link="#0000FF" vlink="#FF0000" text="#000000" > <table border=0 cellspacing=0 cellpadding=0 width=650 align="center"> <tr valign="top" align="left"> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=78></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=15></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=6></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=7></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=98></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=72></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=7></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=9></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=3></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=19></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=14></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=8></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=27></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=10></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=12></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=47></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=2></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=4></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=7></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=2></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=3></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=20></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=27></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=36></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=22></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=39></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=2></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=34></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=4></td> <td><img src="http://www.geocities.com/clipart/pbi/c.gif" height=1 width=1></td> </tr> <tr valign="top"> <td colspan=46 height=40></td> </tr> <tr valign="top"> <td colspan=5 height=50></td> <td align="center" colspan=31 rowspan=1 width=388><b><i><font color="#000099" face="Helvetica" size="+2"><span style="font-size:24">Membership Application</span></font></b></i></td> <td colspan=10 height=50></td> </tr> <tr valign="top"> <td colspan=46 height=28></td> </tr> <tr valign="top"> <td colspan=44 rowspan=1 width=646><b><font color="#000099" face="TimesRoman"><span style="font-size:14">Membership is free and open to all concerned persons, except those within the long term care industry for whom membership might represent a conflict of interest. Employees of long term care facilities, such as nurses, aides and social workers are eligible for Associate (non-voting) membership.</span></font></b></td> <td colspan=2 height=59></td> </tr> <tr valign="top"> <td colspan=46 height=36></td> </tr> <tr valign="top"> <td colspan=7 height=3></td> <form method=post action="http://us.1.p7.webhosting.yahoo.com/forms?login=voicesforqualitycare"> <td colspan=2 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=25 name="Name" value="" ></td> <td colspan=37 height=3></td> </tr> <tr valign="top"> <td colspan=3 height=19></td> <td align="right" colspan=3 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Name</span></font></b></td> <td colspan=1 height=19></td> <td colspan=37 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=15></td> </tr> <tr valign="top"> <td colspan=7 height=3></td> <td colspan=2 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=25 name="Address 1" value="" ></td> <td colspan=37 height=3></td> </tr> <tr valign="top"> <td colspan=3 height=19></td> <td align="right" colspan=3 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Address 1</span></font></b></td> <td colspan=1 height=19></td> <td colspan=37 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=15></td> </tr> <tr valign="top"> <td colspan=7 height=3></td> <td colspan=2 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=25 name="Address 2" value="" ></td> <td colspan=37 height=3></td> </tr> <tr valign="top"> <td colspan=3 height=19></td> <td align="right" colspan=3 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Address 2</span></font></b></td> <td colspan=1 height=19></td> <td colspan=37 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=15></td> </tr> <tr valign="top"> <td colspan=7 height=3></td> <td colspan=2 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=25 name="City" value="" ></td> <td colspan=37 height=3></td> </tr> <tr valign="top"> <td colspan=3 height=19></td> <td align="right" colspan=3 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">City</span></font></b></td> <td colspan=1 height=19></td> <td colspan=37 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=15></td> </tr> <tr valign="top"> <td colspan=7 height=3></td> <td colspan=2 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=25 name="State" value="" ></td> <td colspan=37 height=3></td> </tr> <tr valign="top"> <td colspan=3 height=19></td> <td align="right" colspan=3 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">State</span></font></b></td> <td colspan=1 height=19></td> <td colspan=37 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=15></td> </tr> <tr valign="top"> <td colspan=7 height=3></td> <td colspan=2 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=25 name="Zip" value="" ></td> <td colspan=37 height=3></td> </tr> <tr valign="top"> <td colspan=3 height=19></td> <td align="right" colspan=3 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Zip</span></font></b></td> <td colspan=1 height=19></td> <td colspan=37 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=15></td> </tr> <tr valign="top"> <td colspan=7 height=3></td> <td colspan=2 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=50 name="Email" value="" ></td> <td colspan=37 height=3></td> </tr> <tr valign="top"> <td colspan=3 height=19></td> <td align="right" colspan=3 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Email</span></font></b></td> <td colspan=1 height=19></td> <td colspan=37 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=15></td> </tr> <tr valign="top"> <td colspan=7 height=3></td> <td colspan=2 rowspan=2 width=170><INPUT type=TEXT size=20 maxlength=25 name="Phone" value="" ></td> <td colspan=37 height=3></td> </tr> <tr valign="top"> <td colspan=3 height=19></td> <td align="right" colspan=3 rowspan=1 width=99><b><font color="#000099" face="Helvetica"><span style="font-size:14">Phone</span></font></b></td> <td colspan=1 height=19></td> <td colspan=37 height=19></td> </tr> <tr valign="top"> <td colspan=46 height=28></td> </tr> <tr valign="top"> <td colspan=26 height=15></td> <td colspan=5 rowspan=1 width=15><INPUT type="checkbox" name="Resident" value="I am or was a resident" ></td> <td colspan=4 height=15></td> <td colspan=5 rowspan=2 width=85><b><font color="#000099" face="Helvetica"><span style="font-size:14">Resident</span></font></b></td> <td colspan=6 height=15></td> </tr> <tr valign="top"> <td colspan=35 height=4></td> <td colspan=6 height=4></td> </tr> <tr valign="top"> <td colspan=46 height=7></td> </tr> <tr valign="top"> <td colspan=25 height=1></td> <td colspan=5 rowspan=2 width=15><INPUT type="checkbox" name="Friend" value="I have a friend" ></td> <td colspan=4 height=1></td> <td colspan=5 rowspan=3 width=50><b><font color="#000099" face="Helvetica"><span style="font-size:14">Friend</span></font></b></td> <td colspan=7 height=1></td> </tr> <tr valign="top"> <td colspan=1 height=14></td> <td colspan=19 rowspan=13 width=378><b><font color="#000099" face="Helvetica"><span style="font-size:14">If you are or were a resident or if you have or had a friend or family member in a long term care facility, please check all that apply and tell us what facility you or they are or were a resident of in the comments or questions area below.</span></font></b></td> <td colspan=5 height=14></td> <td colspan=4 height=14></td> <td colspan=7 height=14></td> </tr> <tr valign="top"> <td colspan=1 height=4></td> <td colspan=14 height=4></td> <td colspan=7 height=4></td> </tr> <tr valign="top"> <td colspan=1 height=9></td> <td colspan=26 height=9></td> </tr> <tr valign="top"> <td colspan=1 height=15></td> <td colspan=5 height=15></td> <td colspan=5 rowspan=1 width=15><INPUT type="checkbox" name="Family" value="I have family" ></td> <td colspan=4 height=15></td> <td colspan=5 rowspan=2 width=50><b><font color="#000099" face="Helvetica"><span style="font-size:14">Family</span></font></b></td> <td colspan=7 height=15></td> </tr> <tr valign="top"> <td colspan=1 height=4></td> <td colspan=14 height=4></td> <td colspan=7 height=4></td> </tr> <tr valign="top"> <td colspan=1 height=9></td> <td colspan=26 height=9></td> </tr> <tr valign="top"> <td colspan=1 height=15></td> <td colspan=5 height=15></td> <td colspan=5 rowspan=1 width=15><INPUT type="checkbox" name="Now" value="true" ></td> <td colspan=4 height=15></td> <td colspan=5 rowspan=2 width=50><b><font color="#000099" face="Helvetica"><span style="font-size:14">Now</span></font></b></td> <td colspan=7 height=15></td> </tr> <tr valign="top"> <td colspan=1 height=4></td> <td colspan=14 height=4></td> <td colspan=7 height=4></td> </tr> <tr valign="top"> <td colspan=1 height=9></td> <td colspan=26 height=9></td> </tr> <tr valign="top"> <td colspan=1 height=15></td> <td colspan=5 height=15></td> <td colspan=5 rowspan=1 width=15><INPUT type="checkbox" name="Past" value="true" ></td> <td colspan=4 height=15></td> <td colspan=5 rowspan=2 width=50><b><font color="#000099" face="Helvetica"><span style="font-size:14">In Past</span></font></b></td> <td colspan=7 height=15></td> </tr> <tr valign="top"> <td colspan=1 height=4></td> <td colspan=14 height=4></td> <td colspan=7 height=4></td> </tr> <tr valign="top"> <td colspan=1 height=9></td> <td colspan=26 height=9></td> </tr> <tr valign="top"> <td colspan=1 height=7></td> <td colspan=5 height=7></td> <td colspan=5 rowspan=2 width=15><INPUT type="checkbox" name="Maryland" value="true" ></td> <td colspan=4 height=7></td> <td colspan=9 rowspan=3 width=149><b><font color="#000099" face="Helvetica"><span style="font-size:14">In Maryland</span></font></b></td> <td colspan=3 height=7></td> </tr> <tr valign="top"> <td colspan=25 height=8></td> <td colspan=4 height=8></td> <td colspan=3 height=8></td> </tr> <tr valign="top"> <td colspan=34 height=4></td> <td colspan=3 height=4></td> </tr> <tr valign="top"> <td colspan=46 height=9></td> </tr> <tr valign="top"> <td colspan=25 height=15></td> <td colspan=5 rowspan=1 width=15><INPUT type="checkbox" name="Other State" value="true" ></td> <td colspan=4 height=15></td> <td colspan=8 rowspan=2 width=147><b><font color="#000099" face="Helvetica"><span style="font-size:14">Other State</span></font></b></td> <td colspan=4 height=15></td> </tr> <tr valign="top"> <td colspan=34 height=4></td> <td colspan=4 height=4></td> </tr> <tr valign="top"> <td colspan=46 height=28></td> </tr> <tr valign="top"> <td colspan=1 height=20></td> <td colspan=10 rowspan=4 width=294><b><font color="#000099" face="Helvetica"><span style="font-size:14">Are you now employed in a nursing home<br>or other long term care facility?  If yes, please tell us your position in the comments or questions area below.</span></font></b></td> <td colspan=35 height=20></td> </tr> <tr valign="top"> <td colspan=1 height=15></td> <td colspan=2 height=15></td> <td colspan=2 rowspan=1 width=15><INPUT type="checkbox" name="Facility Employee?" value="Yes" ></td> <td colspan=2 height=15></td> <td colspan=4 rowspan=2 width=50><b><font color="#000099" face="Helvetica"><span style="font-size:14">Yes</span></font></b></td> <td colspan=2 height=15></td> <td colspan=5 rowspan=1 width=15><INPUT type="checkbox" name="Facility Employee?" value="No" ></td> <td colspan=4 height=15></td> <td colspan=5 rowspan=2 width=50><b><font color="#000099" face="Helvetica"><span style="font-size:14">No</span></font></b></td> <td colspan=9 height=15></td> </tr> <tr valign="top"> <td colspan=1 height=4></td> <td colspan=6 height=4></td> <td colspan=11 height=4></td> <td colspan=9 height=4></td> </tr> <tr valign="top"> <td colspan=1 height=41></td> <td colspan=35 height=41></td> </tr> <tr valign="top"> <td colspan=46 height=46></td> </tr> <tr valign="top"> <td colspan=2 height=28></td> <td colspan=10 rowspan=4 width=296><b><font color="#000099" face="Helvetica"><span style="font-size:14">Voices maintains an Email ListServe for its membership so that we can exchange ideas, disseminate information and discuss business issues. Would you like to join that ListServe?</span></font></b></td> <td colspan=34 height=28></td> </tr> <tr valign="top"> <td colspan=2 height=15></td> <td colspan=2 height=15></td> <td colspan=2 rowspan=1 width=15><INPUT type="checkbox" name="Join Members Listserve?" value="yes" ></td> <td colspan=2 height=15></td> <td colspan=4 rowspan=2 width=50><b><font color="#000099" face="Helvetica"><span style="font-size:14">Yes</span></font></b></td> <td colspan=2 height=15></td> <td colspan=5 rowspan=1 width=15><INPUT type="checkbox" name="Join Members Listserve?" value="No" ></td> <td colspan=4 height=15></td> <td colspan=5 rowspan=2 width=50><b><font color="#000099" face="Helvetica"><span style="font-size:14">No</span></font></b></td> <td colspan=8 height=15></td> </tr> <tr valign="top"> <td colspan=2 height=4></td> <td colspan=6 height=4></td> <td colspan=11 height=4></td> <td colspan=8 height=4></td> </tr> <tr valign="top"> <td colspan=2 height=48></td> <td colspan=34 height=48></td> </tr> <tr valign="top"> <td colspan=46 height=66></td> </tr> <tr valign="top"> <td colspan=8 height=22></td> <td align="center" colspan=19 rowspan=1 width=240><b><font color="#000099" face="Helvetica"><span style="font-size:14">Comments or Questions</span></font></b></td> <td colspan=19 height=22></td> </tr> <tr valign="top"> <td colspan=46 height=12></td> </tr> <tr valign="top"> <td colspan=4 height=184></td> <td colspan=37 rowspan=1 width=490><TEXTAREA wrap=PHYSICAL rows=10 cols=58 name="Comments" > </TEXTAREA></td> <td colspan=5 height=184></td> </tr> <tr valign="top"> <td colspan=46 height=25></td> </tr> <tr valign="top"> <td colspan=10 height=33></td> <td colspan=9 rowspan=1 width=83><INPUT type="submit" name="FormButton2" value="Submit" ></td> </form> <td colspan=27 height=33></td> </tr> </table> </body> </html>  </div> </td> </tr></table></body>