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2. HEAL Newsletter Format Desired

   Please select the method in which you would like the newsletter.

   1. Electronic Newsletter (Email)
   2. Postal Newsletter (Address)
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Email
17. Thank you for signing up for the HEAL newsletter
Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field