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

Please send me __________ additional VPF brochures.

I want to serve as a resource for the Foundation in my field or specialty. (If you want to be available to patients, please send a resume, brochure of your practice, and/or letter about your background to the Executive Director.)
Name

Address

City / State or Province / Zip or Postal Code

Country

Telephone Number (Work)

Best times to call

Facsimile

E-mail address

Field (Medical doctor, physical therapist, scientist, psychologist, etc.)

How did you hear about the Foundation?



			
Please print out a copy of this form and mail with your fee of $60

					plus international postage, if any, to:
			

				
The VP Foundation

						Post Office Drawer 177

						Graham, NC 27253

						USA

					
				

					
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