Application for Membership
North Carolina Chemical Injury Network
Please --- NCCIN is a support group for persons (or support persons) with CFIDS, Fibromaylgia, Chemical Sensitivities or any illness or injury related to exposure to chemicals or the environment. Doctors and Medical personel, Attornies, and other professional persons are at as great a risk of having an illness or illness as anyone.   We welcome anyone with Chemically Induced Illness or Injury or their support person. We exclude no one because of their occupation. This is a North Carolina Group.
Name
City/state
e-mail Address
Age
Male/female
Years Education
Degree Received
What Chemical or Pesticide to you relate your Illness/injury
If you are a support person please indicate relationship.