Network Member Application
After submission, your application will be sent to the NCHN Board of Directors for approval and you will receive an email regarding your application status shortly. Membership dues are billed annually.
Enter information about your network below.
Street Address (if different)
Most recent fiscal year operating expenses:
NCHN annual dues are determined by the member organization’s most recent fiscal year’s operating expenses, as reported on their 990 form and/or other Internal Revenue Service reporting format, including expenditures for all programs and services, including programs supported by grant funds, and any additional companies that are under the management of the parent organization.
Network Logo (optional - will be added to your profile at NCHN.org if attached)
Total Number of Network Members
Member Composition: What is the composition of your network (e.g., hospitals, clinics, mixed)? (Enter the number of each type of member)
Number of Members
Behavioral Health Providers
Community Health Centers
Hospital-Owned Provider Clinics
Large Hospitals (>200 beds)
Long-Term Care Facilities
Medium Hospitals (51-200 beds)
Oral Health Providers
Physician Owned Clinics
Post-Secondary Educational Institutions
Public Health Departments
Rural Health Clinics
Small Hospitals (26-50 beds)
If you indicated "Other" above, please specify other types of members:
Enter types of members that are included in "Other"
Location of Members
Enter information for your network director or the primary contact for NCHN
Director Photo (optional - will be added to your profile at NCHN.org if attached)
Which of the following NCHN benefits are you most interested in?
Annual Conference - Discounted registration
Leadership Experience - Discounted registration
Hospital Network Leader Roundtable Calls
Quarterly Information and Special Interest Calls
Staying up to date on network related news with NCHN's monthly e-News and periodic informational emails
Opportunities to connect with other health network leaders (via member listserv and other collaboration)
Access to NCHN Staff
If you indicated "Other" above, please specify:
Would you like to have other staff members receive the NCHN e-News (distributed on the first Tuesday of every month)? If so, please add these below:
Name (First & Last)