How to Apply

1. Obtain a diagnosis from neurologist/doctor confirming MS
2. Register with MS Moments and download and fill out form below:
3. Sign Waiver
4. 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 *

Choose Grant Options (please note that all options may not be approved ) *

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

*Gym Membership Location Requested (Please include date of birth of each member) *

*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