America
RegistryHearts
Across America
Registry
To:
The Chemically Injured and ILL Nationwide
From:
the “MCS” Beacon of Hope Foundation
Julia
and I want to encourage everyone to register with the “MCS” Hearts Across
America Registry. By adding your name to this national registry you will be
helping us to help “You”! Our
mission, with your help, is to one day be able to assist people in obtaining
their special accommodations and provide safer emergency, assisted living and
residential villages for the chemically ill.
The
registry keeps a running account of the names, numbers and states where the
chemically ill live, their needs for safer housing and other special
accommodations.
As
housing opportunities become available, the names of those registered will be
randomly drawn to determine those chosen for the first options available. There
will be subsequent drawings as units or spaces become available.
Completed
forms, signatures and a donation are required to register.
Your
tax-deductible
gift will help defray the cost of creating and maintaining the registry, to help
raise awareness and education as preventative measures and will go towards
providing assistance and support in acquiring adequate medical care and in
locating and procuring special accommodations deemed now medically necessary;
such as purifiers, oxygen, etc and of course for emergency, assisted and
residential housing opportunities. Eighty (80%) to ninety (90%) of all donations
will go directly to addressing the needs of those with toxic injuries. We accept
checks and all major credit cards:
If
you are unable to print out the following registry form please send a self
addressed, stamped envelope marked “Registry”
to the address below and one will be provided
“MCS”
Hearts Across America Registry
601
Starkey Road #99 ~ Largo, Florida 33771
“Attention”
Julia Williams
Print
page 2 and send completed forms and donations to: Julia. Address is repeated on
page 2 for your convenience.
We
thank you for your support and generosity.
Wishing
Everyone Healthier & Happier Tomorrows!
Peggy
& Julia
Peggy Troiano,
Executive Director:
E-mail:
mcsbeaconofhope@yahoo.com
Julia Williams, Director:
E-mail:
juliamcs2004@yahoo.com
Page
2
If
you need more space to write please, write on back of the sheet or add an extra
sheet of paper. We need to be able to read the
information
clearly so we can add info to our files.
Please
Print or Type:
Your
name:
Address:
City,
State and Zip:
Ph
# ( )
Fax # ( )
e-mail:
Are
you chemically sensitive? Yes
( )
No ( )
Have you been diagnosed? Yes
( )
No ( )
Diagnosis:
MCS ( )
CFIDS ( )
FM ( )
GWS ( )
other ( )
Doctor:
If
known, source of exposure:
Special
accommodations if needed: Housing (
) Medical
Equipment ( )
Job ( )
Other ( )
By
adding your name to the “open” file, your name, city, state and other listed
information may be released to professional organizations that are working in
support of health & environmental issues to benefit the chemically ill and
as proof of the need for safe housing, special accommodations and to pin-point
any problematic areas within your state and nationwide.
By
adding your name to the anonymous file your signature will be counted, however
no personal information will be released. In our opinion, this might lessen your
chances of having your specific issues addressed on local, regional and state
levels and might hamper the hope, help and solutions needed in your specific
area.
PLEASE
PUT MY NAME IN THE: OPEN FILE (
)
ANONYMOUS
FILE ( )
Signature:
Date:
I
wish to make a donation In Loving Memory of
who lost the
battle against “MCS”.
I
am “not” toxically injured but I am concerned about today’s Health
&Environmental issues and want to help!
Sign me on as a Supporter:
Name:
Date:
Donation
by check ( ) or credit
card ( )
Type
of card:
Card
#
Expiration date
Amount
Signature:
Date
Mail
to:
“MCS”
Hearts Across America Registry
Attention:
Julia Williams
601
Starkey Road #99 ~ Largo, Florida 33771
“MCS Beacon of Hope Foundation, a project of the Congressional District Programs – a registered 501(c)(3).”