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TLC IN LTC

TLC IN LTC
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Membership Form

Join TLC in LTC, a statewide coalition of families and friends of residents.

Enter your information in the spaces provided below.
Title:
First Name:	Last Name:
Street Address:	Apt. #
City:	State:	Zip Code:
Country:
E-mail address:
Agency (if applicable):		Name of Facility:
Town of Facility:


(Optional)
1. Do you have a family member or friend in a nursing home or long-term care facility?	Yes	No
2. Does your loved one's facility currently have a Family Council?	Yes	No
3. Do you have ownership, property, economic or pecuniary interest in a long-term care facility?	Yes	No
4. Do you have a business, partnership, or corporation which owns, invests in, controls or derives economic benefits from one or more long-term care facilities?	Yes	No
5. Do you have a spouse, parent, minor child, or related adult living in the same residence with an economic or business interest as listed above?	Yes	No

We can send information specific to your interest or concern. Simply leave a comment in the space provided below. Also, please share with us your background or any skills that you would be willing to share in helping TLC in LTC advocate for residents.

For us to receive this information, print this form and mail to:

TLC in LTC
620 North Walnut Street
Springfield, IL 62702

Phone: (217) 523-8419
Toll Free: (800) 842-8538
Fax: (217) 523-8493
E-mail: email@tlcinltc.org

We also accept e-mail submissions as long as all the necessary information is provided. Thank you for your interest in becoming a member of Tender Loving Care in Long-Term Care of Illinois.