How to Apply (Back Up 10/11/2022)

1. Obtain a diagnosis from neurologist/doctor confirming MS
2. Fill out form below:
3. Write Your Story

Life Before MS
Your Diagnosis
Life Since
How MS Moments will Help You

MS Moments Application

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Names of Family Members Utilizing Services *

My First Choice is: CHOOSE GRANT OPTIONS (PLEASE NOTE THAT ALL OPTIONS MAY NOT BE APPROVED ) *

I would like to request massage therapy I would like to request a gym membership I would like to request acupuncture I would like to request house cleaning

*If Gym Membership is selected - please provide name of Gym requesting and location (Please include date of birth of each member) PLEASE NOTE WE REQUEST YOU USE THE GYM MEMBERSHIP AT LEAST 4 TIMES PER MONTH *

*Are you currently a member at this club? *

Yes No

Write your Story *

How did you find out about MS Moments? *

Attach a copy of diagnosis from Doctor *

Max file size: 20MB

Submit