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"Out of My Head" Order Form

One-hour performance followed by one-hour healthcare panel discussion with legislators, patients, nurses, union leaders and media addressing the health-care issues raised in the play.

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T.H.E. BRAIN TRUST
186 Hampshire Street
Cambridge, MA 02139

 

# ordered ___  DVD (minimum $30 donation)       amount included: _____
# ordered ___   VHS (minimum $25 donation)       amount included: _____
 
Additional Donation earmarked for
T.H.E. BRAIN TRUST Advocacy Programs             amount included: _____
 
                    TOTAL amount included: _____
   
Checks may be made payable to: T.H.E. BRAIN TRUST
   
Or, Bill my credit card             Acct #: ___________________________________
   
Expiration Date: ___________ ____ VISA    ____ AMEX     ____ MC
   
Signature: ______________________ Phone number: __________________
   
Billing Address: Mailing Address (if different from billing address):
   
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________



    © 2004 The Healing Exchange BRAIN TRUST; 186 Hampshire Street, Cambridge, MA 02139-1320; Telephone: 617-876-2002; Fax: 617-876-2332
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