Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60 Page 61 Page 62 Page 63 Page 64QUALIFICATION APPLICATION (Please Print) Last Name __________________________________ First Name___________________________ Street (no PO boxes)_______________________________________________ Apt. ___________ City ____________________________ County ______________ State ________ Zip __________ Phone ________________________ Email ________________________ Date of Birth _________ Alternate Contact __________________________________________________________________ Relationship _________________________________________ Phone ______________________ Physician’s Name __________________________________________________________________ Physician’s Fax ______________________ Phone ______________________ When were you diagnosed with MS? __________ Current major symptoms _____________ ___________________________________________________________________________________ Is it OK for us to leave a detailed message about this application on your voicemail or with another household member, if you are not available? ■ Yes ■ No Do you or your spouse have medical insurance? ■ Medicare ■ Medicaid ■ Private carrier Monthly gross income $_______ Monthly expenses $_______ Disposable income $_______ Choose One Option Only: (See next page for pictures and details) ____ Steele Classic Cooling Vest Kit: Universally Sized, Color: ■ Blue ■ Tan (includes the vest and 2 sets of 15oz Gel Ice Thermo-strips) ____ Steele Cool UnderVest Kit: Universally Sized, Color: Tan Only (includes the vest and 2 sets of 15oz Gel Ice Thermo-strips) ____ Polar Cool Comfort Evaporative Kit: (full vest, hat, necktie, wristbands) Size: ■ S ■ M ■ L ■ XL ■ XXL ■ XXXL - Color: ■ Blue ■ Khaki Hat: ■ bucket ■ baseball cap ■ straw ____ Polar Fashion Cooling Vest Kit: (full vest,neck wrap, hat) ■ Female Vest ■ Male Vest - Size: ■ S ■ M ■ L ■ XL ■ XXL ■ 3XL Color: ■ Black ■ Khaki ■ Baby Blue ■ Pink - Hat: ■ bucket ■ baseball cap ■ straw Type of Cooling Pack: ■ Kool Max Water-Based Cooling Pack ■ 58 Degree F Phase Change Pack ____ Heat Relief Depot Accessory Package: (hat, necktie, wristbands) Hat Size: ■ S ■ M ■ L ■ XL - Color: ■ Navy ■ Khaki Please include a written confirmation of diagnosis of MS from your physician. ■ 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. Applicant Signature: _____________________________________ Date: ___________ Send your completed application to: The Multiple Sclerosis Foundation, 6520 N. Andrews Ave., Fort Lauderdale, FL 33309 COOLING PROGRAM COOLING PROGRAM