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Educational Dinners
MS Yoga-Free
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 ONE OF THE BELOW OPTIONS (PLEASE NOTE THAT ALL CHOICES 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
My Second Choice is: CHOOSE ONE OF THE BELOW OPTIONS (PLEASE NOTE THAT ALL CHOICES MAY NOT BE APPROVED. iF YOU DO NOT HAVE A 2ND,3RD,4TH CHOICE-PLEASE LEAVE BLANK)
*
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
My Third Choice is: CHOOSE ONE OF THE BELOW OPTIONS (PLEASE NOTE THAT ALL CHOICES 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
My Fourth Choice is: CHOOSE ONE OF THE BELOW OPTIONS (PLEASE NOTE THAT ALL CHOICES 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 you have a preferred service provider for each choice, please indicate in this field (ex: Massage=XXX). If you do not have a preferred provider, leave blank and MS Moments will provide recommendations. If selecting a gym membership, please provide date of birth of each member) PLEASE NOTE WE REQUEST YOU USE THE GYM MEMBERSHIP AT LEAST 4 TIMES PER MONTH
*
*For Gym Memberships, 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
*
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Home
About
About MS Moments
Service Providers
>
Acupuncture
Gym/Health Clubs
House Cleaning
Massage Therapy
Board of Directors
Sponsors
About MS
Annual Report
Get Involved
Events
Donate
Volunteer
Shop
News
Videos
Blogs
How to Apply
Contact
FAQ
Educational Dinners
MS Yoga-Free