Professional Memberships ($60)

The VP Foundation Professional Membership ($60)

I want to receive and other information from the Foundation.

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.)

Please send me __________ additional VPF brochures.


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 Box 755
Graham, NC 27253
USA


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