"MCS"
Beacon of Hope
Hearts
Across 
America
Registry
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
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
www.mcsbeaconofhope.com
“MCS Beacon of Hope Foundation, a project of the
Congressional District Programs – a registered 501(c)(3).”