Multiple Sclerosis Foundation - Cooling Program Form

Date of Birth(mm/dd/yyyy):

When were you diagnosed with MS?((mm/dd/yyyy)):

Current Major Symptoms:

May we leave a detailed message about this application on your voice mail or with another household member, if you are not available?:

Do you or your spouse have medical insurance?:

MedicareMedicaidPrivate Carrier

Package Type:

Steele Classic Cooling Vest
Thermapparel Cooling Vest
Polar Cooling Accessory Kit (hat, neck wrap, hat)
Polar Fashion Vest Kit (full vest, necktie, hat)
Heat Relief Depot Accessory Package (hat, necktie, wristband)

I hereby release and hold the Multiple Sclerosis Foundation, Inc. harmless from, against, and in respect of all claims, injuries, actions, demands, suits, losses, liability or other damages that may be incurred as a result of accepting goods or services.:

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