ONLINE APPLICATION

Company/Organization Name* 
First Name* 
Last Name*
 
Street Address*

City*
 
State*
  
Zip* 

Phone*

Email*

PROVIDER INFORMATION
Total # of licensed beds

Date of last DHEC Inspection

Type of Ownership: 

Do you accept Medicaid?
Yes   No
Operations Director/Regional Director 

Email

PAYMENT 
Total Dues: $ 
Card Type: 

Credit Card# 

Expiration Date*

Security Code 

Name on Card 

I (we) hereby submit the information above for the consideration of the Membership Committee and/or theBoard of Directors and apply for membership with the SC Association of Residential Care Homes. I (we)agree to comply with all rules and regulations as set forth by SCARCH standards including the bylaws andCode of Ethics. Please submit method of payment at time of application and payment will only be processed after approval for membership. Membership will be reviewed and an answer will be given within seven (7) days of submission. Please note 25% of SCARCH dues are allocated for lobbying, consulting & legislative efforts and are not allowable as a business expense.
Signature of Approval*  

Date 

Please note 20% of dues are allocated to lobbying, consulting & legislative
efforts and are not allowable as a business expense.
   


PROVIDER:
All assisted living or residential care communities.
Dues are based on number of DHEC licensed beds.

15 beds or more:
$19 per licensed bed

Less than 15 beds:
Flat rate of $275