I HEREBY APPLY, on behalf of the hereinafter named nursing facility, residential care facility, personal care home, assisted living facility, or sub-acute facility, for membership in the Mississippi Health Care Association and the American Health Care Association. I understand that as an applicant if my membership application is accepted, my facility will conform to the Code of Ethics of both Associations, and their respective Constitutions and Bylaws. The information supplied hereinafter is accurate to the best of my knowledge and belief. I hereby authorize the Mississippi Health Care Association to make such inquiries, as it may deem appropriate and desirable, to verify the qualifications of the applicant facility for membership therein.

  • Applicant Name * Required
  • Mailing Address
  • Physical Address
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • (Proprietary, Church Non-profit)

If you have questions, please call Dina Russell at (601) 898-8320 or e-mail your questions to dina@mshca.com.