Application Cover Letter
Application Cover Letter
Here you will find an Application, Medical History form and Policy Sheet. Please fill out all forms and mail with your fee in check or money order made out to “S.T.R.C., Inc.” to:
Abigail Brown, Director, S.T.R.C., Inc.
5 Bisbee Ct. 109-238 Santa Fe, NM 87508
OR Email or Fax with credit card information. Please choose from 2 plans: PLAN A is an expansion of our original program listed below but the following complimentary enhancements have been added: the Instructional Photo Manual and Video, an afternoon at a day spa warm therapy pool and Jacuzzi, a full-body massage by Licensed Therapist, Myra Jacobs, the clinic cookbook Come & Dine, and a more closely structured follow-up program. The fee for Plan A is $1,500.00. PLAN B is our original program that does not include the above stated enhancements, but is the program clients have used for years to effect an ongoing recovery, and the fee is the usual $900.00. Both plans include all classes Tuesday through Friday, your Program Guide (Plan B), supervised exercise program, a daily back/neck massage, 2 books, a generous supply of high quality natural vitamins, nutritional seminar with free ongoing nutritional counseling, a local availability of a small library on current S.T. research, viewing of 2 inspirational films, attitudinal encouragement for getting through your recovery program successfully, transportation if needed to and from your motel, a tourist orientation package, free inclusion in the clinic by a spouse or relative and lunches for them here at the clinic, all luncheon meals, including a luncheon (for clients) at a nice restaurant, plus follow-up consultation for a two year period, including free quarterly Updates. Your check will not be cashed until you are in town for the clinic. Any amount offered above either fee of $1,500.00 or $900.00 is fully tax deductible, greatly appreciated, and a receipt will be mailed to you with your Tourist Information Package. We also accept Visa and MasterCard.
Please note: This clinic is for those who are willing and committed to do the exercises daily for probably a year or more to achieve recovery and then regularly for the rest of your life to maintain recovery. Exercise, a sensible diet and a close relationship with God are all good for you; what do you have to lose? Are you a fighter? You will need to be, because the program will be effective only if you are determined and consistent. Because your muscles have been in spasm and your body misaligned for some time, you will likely experience an increase in stiffness and spasms when you begin your program, as your body reacts to the exercises. This is normal and may last awhile. It is vital to "tough out" this period of time and to exercise through the discomfort until you begin to come into your recovery. I encourage clients to continue working with their doctors and taking their medication for as long as is necessary. This program is compatible with the use of Botox if you are on that treatment. The clinic takes no more than two clients at a time. If someone needs to be seen alone, a sensitive consideration of that request will be made.
Please return all forms and keep the Policy Sheet for your records. Remember, you will be responsible for making your own motel/hotel reservations and the cost of all room and board with the exception of luncheon meals Tuesday through Friday. Shuttle service is available from Albuquerque Airport to your motel. A map to the clinic will be included with your Tourist Information Package which will be mailed to you upon acceptance to the clinic. I look forward to hearing from you and working with you.
Sincerely,
Abigail Brown, Director S.T.R.C., Inc.
Spasmodic Torticollis Recovery Clinic, Inc.
5 Bisbee Ct. 109-238 - Santa Fe, NM 87508
Phone 1-(800) 805-9976 - Local (505) 473-0556 - Fax (505) 424-3994
REGISTRATION - APPLICATION Date:_______________________
This form must be completed, signed and mailed in at least two weeks prior to desired date of entry into the program. __________MALE________ FEMALE
NAME:____________________________________________________________________________
STREET ADDRESS:__________________________________________________________________
CITY: ______________________________________________STATE_________ ZIP______________
COUNTRY:______________________________________________________
PHONE: Home (_____ )___________________ Work (_____ )_________________________
FAX: ( _____)___________________________________
EMAIL______________________________________________________________________________
AGE:________ HEIGHT_________ WEIGHT___________
MARITAL STATUS: _____married _____single _____divorced _____separated _____widowed
# OF CHILDREN UNDER YOUR CARE AT HOME? ____ages?___________________________________
ARE YOU EMPLOYED?______ WHERE?___________________________________________________
NATURE OF WORK? (i.e. do you sit, stand? Is it physically and/or emotionally stressful?)____________
__________________________________________________________________________________
SPOUSE’S FIRST NAME__________________________________________
Will your spouse or relative be sitting in on your clinic week and joining us for lunch each
day? If so, any dietary restrictions?__________________________________________________________
Are you willing to commit yourself to a 4 day program here in Albuquerque, New Mexico,
abide by S.T.R.C. policies while here and dedicate yourself without compromise, as much
as is possible, to following the program on your own at home over a long-range period
of time?________________
WHAT WEEK ARE YOU INTERESTED IN COMING? 1st Choice:_____________________
2nd Choice________________________________?
The program is 4 part:
* Exercise (non-aerobic)
* Famous S.T.R.C. Backrub & trigger point work
* Nutrition principles
* Attitudinal work with applied scriptural principles
You will be in the clinic Tuesday through Friday from 9:00 am until 3:00 pm. You will be responsible for making your own hotel/motel arrangements, and all transportation to and from your hotel/motel will be provided if needed. Once this application has been accepted, you will be sent a confirmation of acceptance and an Albuquerque Tourist Guide. All luncheon meals will be provided with one restaurant luncheon - gratis S.T.R.C.
WHAT IS YOUR SPIRITUAL PERSUASION?_______________________________________________
Would you be willing to have your reports of ongoing improvement and your before and after photos and testimonial shared with others as a form of encouragement and hope?___________________
It is required that you also fill out and return with your application the enclosed medical questionnaire. All information is strictly confidential.
I am enrolling for (please check one):
________________PREMIER PLAN A $1,500.00________________PLAN B $900.00
The clinic fee:
I am enclosing my fee of $__________________ to cover the cost of the goods and services I
will receive at S.T.R.C. Please make your check or money order payable to “S.T.R.C.,Inc.” and enclose with your application. Your check will not be cashed until you are in town for your clinic week, and you may cancel your plans with full refund any time up until the first day your program is scheduled to begin. After that date, there will be no refund. Any amount given to this work above stated fees is fully tax deductible.
We also accept credit cards: in the case of credit card payment, your card will be charged approximately 3 days prior to your clinic visit. Please fill out the appropriate information below.
Check correct box (Please print very clearly)
______________MasterCard_______________Visa
Card number__________________________________________________________________________
Exp. Date__________ /____________
Name on card (printed)___________________________________________________________________
Signature (unless submitted by email)________________________________________________________
Thank you. We look forward to working with you!
MEDICAL HISTORY
NAME____________________________________________________________
DOES YOUR HEAD TURN TO THE RIGHT OR LEFT?_________________________
DO YOU HAVE ANTEROCOLLIS? (head forward)_______OR RETROCOLLIS? (head back)_____
HOW AND WHEN YOU DEVELOPED S.T._________________________________
_____________________________________________________________________________
HAVE YOU HAD A MEDICAL DIAGNOSIS?_________WHEN?________________
DO YOU HAVE VERTEBRAE OUT OF PLACE?_______SCOLIOSIS (spinal curvature)?_________
DID AN ACCIDENT OR SERIOUS ILLNESS PRECEDE THE ONSET OF S.T.?____YES ____NO
If yes, please exlain __________________________________________________________________
ARE YOU CURRENTLY ILL WITH ANY OTHER DISEASE?________YES _______NO
If yes, explain________________________________________________________________________
ARE YOU UNDER SEVERE STRESS?_____YES ______NO. If yes, explain why:
_____________________________________________________________________________
DO YOU EXPERIENCE PROBLEMS PHYSICALLY WHILE:
______standing ______speaking ______driving______eating ______walking ______all of the above______lying down ______sitting
DO YOU EXPERIENCE TREMORS?______WHERE?________________________________________
DO YOU HAVE PAIN?_______WHERE?___________________________________________________
Is the pain: _____mild_____moderate_____severe
HAVE YOU HAD ANY BOTOX INJECTIONS FOR YOUR S.T.?_______YES ______NO
If yes, have you experienced adverse reactions?__________________________________________
If yes, have you experienced relief from Botox?___________________________________________
ARE YOU CURRENTLY “ON” BOTOX?________Date of last injection________________________
WHAT OTHER MEDICAL, THERAPEUTIC, AND/OR CHIROPRACTIC TREATMENTS HAVE YOU HAD FOR S.T.?_____________________________________________________________________
_____________________________________________________________________________
HAVE THE TREATMENTS MADE YOU WORSE? _____YES _____NO
If yes, explain:_______________________________________________________________________
ARE YOU TAKING ANY PRESCRIPTION DRUGS?________YES ______NO
Which ones?________________________________________________________________________
HAVE YOU HAD ANY RELIEF FROM THESE DRUGS? _____YES _____NO
If yes, explain:_______________________________________________________________________
IF FEMALE, ARE YOU ON HORMONE REPLACEMENT THERAPY (HRT) ?____________
* HAVE YOU HAD SURGERY TO CORRECT YOUR S.T.? _____YES _____NO
If yes, explain and include dates:___________________________________________________________
_____________________________________________________________________________________
HAVE YOU HAD ANY OTHER RECENT SURGERY?_______YES _______NO
If yes, explain and include dates:____________________________________________________________
______________________________________________________________________________________
DO YOU SMOKE?______ DRINK ALCOHOL?_______ EAT SWEETS?__________
HAVE YOU SMOKED IN THE PAST? ________ If yes, explain for how long and when you quit.
____________________________________________________________________________
ARE YOU INVOLVED IN A SPORTS PROGRAM? ____________ IF YES, EXPLAIN:___________
_____________________________________________________________________________
IS YOUR BED: ______hard ______soft ______ medium _______a waterbed _______ airbed
Do you use a pillow? ______YES ______NO Is the pillow: ______Feather ______Foam/Fiber ______Contour ____Buckwheat
DO YOU SLEEP:
______on your back ______on your stomach______on your side ______(which side? ____) _________all of the above
DO YOU SIT IN RECLINERS AND SOFT SOFAS?_______YES ________NO
DO YOU HAVE ANY OF THE FOLLOWING:
______diabetes ______fainting spells______hypoglycemia ______HIV positive______high ____low blood pressure ______arthritis______glaucoma ______dizziness
DO YOU HAVE ANY FOOD OR OTHER ALLERGIES?______YES ________NO
If yes, explain________________________________________________________________________
________________________________________________________________________ADDITIONAL COMMENTS ON YOUR HEALTH THAT MAY NOT HAVE BEEN COVERED (include any special dietary needs or food you can’t eat or don’t like) If vegetarian, do you eat fish? eggs? If “no dairy” do you eat cheese? butter? This information is needed for meal planning.
_____________________________________________________________________________________
_____________________________________________________________________________________
DO YOU LIKE MILDLY HOT SPICY FOODS?__________________________________________________
(P.S. New Mexico’s green chilie is wonderful!!)
I have read, understand and accept the following: (this must be signed if you plan to attend S.T.R.C.)
This is not a medical clinic. I am not medically trained, do not prescribe medication, nor administer medication and accept no responsibility for lack of physical improvement and/or injury in any client. I offer only suggestions based upon my own devastating experience with S.T, and my recovery through application of these principles to my own life. A client’s progress or lack of it will depend solely upon his or her own commitment to and application of the principles laid down in the S.T.R.C. Program Guide.
Client’s name (PRINTED)_____________________________________________________________
Client’s signature (unless submitted by email)_____________________________________________
Date:___________________
Abigail Brown, Director S.T.R.C., Inc.
* Note: If you have had corrective surgery for your S.T., a written doctor’s release address to the clinic is required and MUST be sent before you arrive for your clinic week.
S.T.R.C., Inc.
5 Bisbee Ct. 109-238, Santa Fe, NM 87508
Toll-free 1(800) 805-9976 Email: stclinic@comcast.net
POLICY SHEET (Keep this for your records)
S.T.R.C., Inc. is a nonprofit, tax-exempt 501(C)(3) organization dedicated to helping victims of Spasmodic Torticollis overcome their symptoms and return to a normal life. This program can provide an ongoing recovery but not a cure. There is no known cure for S.T.
You are asked to read and study all the printed material in your S.T.R.C. material that will be provided to you when you arrive. Even after you have committed the exercises to memory, you will need to review the exercises now and then to be sure you are doing them correctly.
Your clinic fee will not be cashed until you are here in Albuquerque. You may cancel plans to attend the Clinic up to the day before your Program begins, and there will be a complete refund. If there is a cancellation after that time, no refund will be provided. A two week advance registration is requested if possible.
Once you you are scheduled for your Clinic, please bring:
1. An exercise outfit - something comfortable and tennis shoes or
comfortable flats. This area is very casual. We are 5000 ft. up in the mountains, so in the winter it can be cold and snowy. Come prepared.
2. An umbrella in the summer months, though we get very little rain.
3. Heating pad and/or gel ice pack (for the motel if you get stiff or sore)
4. A Bible, if you have one (optional)
5. A swim cap (if you need one for the pool) and a swim suit (Plan A only)
PLAN A Schedule
Tuesday: classroom instruction with exercise breaks, "backrub" / trigger point work
Wednesday: classroom instruction, stress management, exercise & nutrition seminar (Professional full-body massage after clinic by Therapist, Myra Jacobs)
Thursday: Exercise & gym work all morning. In the afternoon: 2 inspirational films.
Friday: Exercise, trip to Day Spa. Luncheon at a restaurant, gratis S.T.R.C.! The clinic pays for client's lunch, and we ask that relatives or friends who join us cover their own lunches at the restaurant. Lunches here at the clinic on Tues., Wed., and Thursday are complimentary for everyone. Afternoon: classroom instruction and wrap-up.
Clinic in session 9:00 am until 3:00 pm. On Wednesday you will be done with your massage at approximately 4:30 pm. Please don't be early in the mornings. Thanks!
PLAN B Schedule
Tuesday: classroom instruction with exercise breaks, "backrub" / trigger point work
Wednesday: classroom instruction, stress management, exercise & nutrition seminar
Thursday: Exercise & gym work all morning. Lunch at a restaurant, gratis S.T.R.C.! .The clinic pays for client's lunch, and we ask that relatives or friends who join us cover their own lunches at the restaurant. Lunches here at the clinic on Tues., Wed., and Friday are complimentary for everyone.
In the afternoon: 2 inspirational films.
Friday: Exercise review of stretching and weight work. Classroom instruction and wrap-up.
Clinic in session 9:00 am until 3:00 pm, however, especially with only one client, we are usually finished on Friday by 1 pm or 1:30. Please don't be early in the mornings. Thanks!
The PHYSICAL address of the clinic (not for mail) is
55 Camino Vista Grande
Santa Fe, NM 87508
Note: There is a very sweet, gentle mutt, Gussie and 2 cats, Oliver and Purry Mason. Animals are not allowed in clinic area. Keep this sheet for your records. I look forward to working with you and to rejoicing with you as you come into your recovery!