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: *

 

 
 

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