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.



City / State or Province / Zip or Postal Code


Telephone Number (Work)

Best times to call


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

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