How to Apply

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Educational Dinners
MS Yoga-Free

How to Apply

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 *

Max file size: 20MB

Submit

Home
About
Get Involved
- Events
- Donate
- Volunteer
- Shop
News
- Videos
- Blogs
How to Apply
Contact
- FAQ
Educational Dinners
MS Yoga-Free