Founding Member Application

🎨 Try Different Color Schemes:

Hybrid (Recommended)

Navy base + Orange accents

Pure Academic

Navy/Teal/Gold only

Orange Primary

UC industry standard

Teal Emphasis

Healthcare innovation focus

Limited Opportunity

Only 15 of 30 founding member positions remain. Applications close December 31, 2025.

Institution Information

Please provide details about your institution and urgent care program.

Institution Name *

Institution Type *

City *

State *

Institution Website

Primary Contact

This person will serve as the main liaison with SAUCM™.

First Name *

Last Name *

Title/Position *

Email *

Phone *

Urgent Care Program Details

Tell us about your institution's urgent care activities and interests.

Number of Urgent Care Facilities

Current Activities * Select all that apply

Clinical Care

Research

Education/Training

Fellowship Program

Quality Improvement

Research Interests * Describe your institution's current or planned research activities in urgent care medicine

SAUCM™ Participation Goals * How do you envision your institution contributing to SAUCM™?

Leadership & Governance

Optional: Indicate if you have faculty interested in leadership roles.

Leadership Interest Name any faculty members interested in serving on committees or the board

Additional Information

Additional Comments Any additional information you'd like to share about your application

How did you hear about SAUCM™?

Upload your CV*

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PDF, DOC, DOCX allowed

By submitting this application, you confirm that the information provided is accurate and that you have the authority to represent your institution in this application.