I want to receive The VP Foundation Newsletter and other information from the Foundation.

Please send me __________ additional VPF brochures.
Name

Address

City / State or Province / Zip or Postal Code

Country

Telephone number

E-mail address

Profession or business

How are you related to the sufferer?

How did you hear about the Foundation?



						

			
Please print out a copy of this form and mail with your fee of $45

					plus international postage, if any, to:
			

				
The VP Foundation

						Post Office Drawer 177

						Graham, NC 27253

						USA

					
				

					
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