Membership Application

To apply for membership in the Michigan Trauma Coalition, please fill out the form below. Once we receive your application, we will send you an invoice. Required fields are marked with an asterisk (*).
Hospital Name*

The hospital name you enter here should be the official name of your institution, not a nickname.
Address 1*
This must be a street address so that the Member Map can show your location accurately.
Address 2
City*
State*
Zip*
Website
Membership Type*
Dues: $3,500/year for Level I and Level II trauma centers, $1,000/year fpr Level III trauma centers, and $500/year for Level IV trauma centers.
Level II Pediatric Trauma Center
- Check this box if your institution is also a Level II Pediatric Trauma Center
Burn Center (ABA-verified)
- Check this box if your institution is a Burn Center verified by the American Burn Association.
Primary Contact*
This is the person who will receive the MTC Membership INVOICE and each year's renewal.
Title/Role*
Address*
City*
State*
Zip*
E-mail*
Phone*
Your Hospital/Trauma Center Personnel

Individuals below will have access to the "Members-Only" sections of the MTC website.
Trauma Medical Director
E-mail
Trauma Administrative Director
E-mail
Trauma Program Manager/Coordinator
E-mail
Trauma Registrar 1
E-mail
Trauma Registrar 2
E-mail
Trauma Registrar 3
E-mail
Trauma Registrar 4
E-mail
Injury Prevention Coordinator
E-mail
Trauma Performance Improvement Coordinator 1
E-mail
Trauma Performance Improvement Coordinator 2
E-mail
Outreach Coordinator
E-mail
Research Coordinator 1
E-mail
Research Coordinator 2
E-mail
MCR 1 (MTQIP Clinical Reviewer)
E-mail
MCR 2 (MTQIP Clinical Reviewer)
E-mail
Other Trauma Program Staff
E-mail
Other Trauma Program Staff
E-mail
Other Trauma Program Staff
E-mail
Other Trauma Program Staff
E-mail
Other Trauma Program Staff
E-mail
Other Trauma Program Staff
E-mail
Other Trauma Program Staff
E-mail
Burn Medical Director
E-mail
Burn Manager/Coordinator
E-mail
Burn Registrar
E-mail
Burn Injury Prevention Coordinator
E-mail
Other Burn Program Staff
E-mail
Comments
This field is for validation purposes and should be left unchanged.