Please let us know
about your level(s) of participation in Rescue Health Care Day.
Fax or snail mail
this form to us as soon as possible.
You can make this day successful and help change America.
Fax or snail mail to:
National Coalition of Mental Health Professionals and Consumers, Inc.
P. O. Box 438, Commack, New York 11725
Phone: 1-888-SAY-NO-MC or 516-424-5232
Fax: 516-549-3942
E-Mail: NCMHPC@AOL.COM
Website: http://www.NoManagedCare.org
PLEASE PRINT:
Name of supporting or participating individual or organization:
______________________________________________
Contact person:
Name ________________________________________
Phone ________________________________________
Fax ___________________________________________
E-mail _________________________________________
Address ________________________________________
________________________________________________
Please check as many as apply:
____ Yes, you can use my/our organization's
name as a "Supporter" of Rescue Health Care Day (RHCD) in any
mailings, statements, or advertisements promoting awareness of and participation
in Rescue Health Care Day. Being listed as a "Supporter" means
only that I/we support the idea of a vote of "No Confidence" in
managed care and the need for a national dialogue on alternatives to managed
care. Being a "Supporter" of RHCD does not imply support for or
affiliation with the National Coalition of Mental Health Professionals and
Consumers or any other individual or organization supporting or participating in
RHCD.
____ Yes, you can use my/our organization's name as a "Participant" in
RHCD in any mailings, statements, or advertisements to promote awareness of and
participation in Rescue Health Care Day. Being listed as a
"Participant" means only that I/we will help organize the event and/or
participate in it as a speaker or through some other function. Being a
"Participant" in RHCD does not imply support for or affiliation with
the National Coalition of Mental Health Professionals and Consumers or any other
individual or organization supporting or participating in RHCD.
____ Yes, our organization would like to consider being a "Co-Sponsor"
of RHCD. Co-Sponsors will actively work until April, 2000 to sign on
individuals and/or organizations; obtain media coverage, promote RHCD,
contribute financially to RHCD, etc. Co-Sponsors support an
inclusive dialogue on alternatives and agree to seek out any organization with
an interest in health care regardless of political perspective.
Co-Sponsors will be listed on all literature as such and will be available to
contact organizations for inquiries. Please contact us to discuss
Co-Sponsorship.
____ I/ We would like to be invited to speak at a Teach-In; are available as
speakers
____ I / We will organize or help organize a Teach-in.
____ I/ We will organize or help to organize a
community location for the Hour of Protest
____ I/ We will provide information to our
organization's chapters so that our chapters can organize Teach-Ins, Hour of
Protest location, and/or disseminate flyers.
____ I / We will volunteer to help with phone
calls, disseminating fliers, etc.
____ I/ We have written comments and suggestions
on back or separate page
____ I / We am making a financial contribution to
help make Rescue Health Care Day a success:
Amount: $__________ Circle
one: Check enclosed
Check will be mailed Credit Card
For credit card users:
Name on credit card: (print)
_________________________________________________________
Circle one: AMEX VISA
MASTERCARD
Card # __________________________
Expiration date (mo/yr): __________
Signature
______________________________________
Your
contribution may be deductible as a business expense.
Contributions are not deductible as a non-profit charity.
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