ACTION ALERT MAILING LIST

PLEASE FILL OUT, PRINT AND MAIL TO LTCCC:

242 WEST 30TH STREET

SUITE 306

NEW YORK, NY 10001

 

NAME:_________________________________

ADDRESS: ____________________________________

                  ____________________________________

 

                  ____________________________________

 

E-MAIL ADDRESS: ___________________________

 

TELEPHONE NUMBER: _______________________

 

FAX NUMBER: _______________________________

I AM:

______  A CONSUMER OF LONG TERM CARE SERVICES

______  A RELATIVE OR LOVED ONE OF A CONSUMER OF LONG TERM CARE SERVICES

______  A DIRECT CARE LONG TERM CARE WORKER

_______ AN ADVOCATE

______   OTHER

 

THANK YOU.