THE STAND - Toxic Homefront Empowered Survivors Take All Necessary Defense

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Please fill out the following information. The only required fields are marked by a red asterisk (*). The only information we display is the state and symptoms. No personal information is displayed. --Please do not put your last name in the username section when you register!--

The following form registers you with us as a victim of the water contamination at Camp LeJeune. The Username and Password that you register will give you access to the discussion group with the ability to post messages and reply to messages left by other victims.

We reserve the right to review all pertinent information in regards to exposure and to accommodate only those victims who meet appropriate criteria.

Username	Password
*	*
	Confirm Password
	*
Email Address
*
First Name	Last Name

Address	Address 2nd Line

City	*State, Zip**
	*,
Phone	Fax

*Symptoms (check all that apply)**
Kidney Disease Skin Disorder Heart Disease Diabetes Cancer Liver Disease Miscarriage Lung Disease Allergies Thyroid Disease Parathyroid Disease Neurological Muscle Pain Death of a Child Bladder Cancer Leukemia Crohn's	Muscle Deterioration Cysts Asthma Tumors Learning Disabilities Anemia Ulcers Reproductive Disorders Birth Defects Depression Anxiety Disorder Deceased Relative MS Non-Hodgkins Lymphoma Male Breast Cancer Other
*Dates lived at Camp Lejeune: *
*Location of living quarters: *
*Your filing status: *