Houston Association of Residential Care Homes & Elderly Disabled Adults

Application

Fields marked with a red dot ( ) are required.

Membership Type (Please Check Where Applicable)

Pick one: RenewalNew
Facility:
(must be a Care Provider or Staff Member)
(Dues: $100.00 per year)
Corporate:
(a Company where any employee can participate)
(Dues: $200.00 per year)

Please Complete The Following

First Name:
Last Name:
Date of Birth:
Street Address:
Address (2nd):
City:
State/
Province:
Zip Code: [5 digits]
Email:
Telephone #: (xxx) xxx-xxxx
Cell Phone #: (xxx) xxx-xxxx
Other Phone #: (xxx) xxx-xxxx
Position with Facility
If Other:
Facility/Company Name:
Physical Address:
Mailing Address:
(if different from above)
Business Phone #: (xxx) xxx-xxxx
Fax #: (xxx) xxx-xxxx
Other #: (xxx) xxx-xxxx

Type of Facility (Check all that pertain to your facility only)

Type
If other:
Assisted Living:
Personal Care:
Board & Care:
Other:
TDHS License #:
Select one:
Specializing in what type of Resident/Client?:

Membership Application Agreement

By sending this membership application, I agree to support/provide quality care in a safe and secure environment, our motto is "Caring with Dignity and Compassion".

Month and Year First Joined H.A.R.C.H

Date: MM/DD/YY

CAPTCHA Code

Please enter the text from the image into the textbox before clicking Submit

Mailing Address:
Houston Association of Residential Care Homes (HARCH)
PO BOX 800129
Houston, TX 77280
Phone: 832-978-6200

2nd Address:
7007 Gulf Freeway #222
Houston, TX. 77087