QUALIFICATION 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 okay 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 Please include a written confirmation of diagnosis of MS from your physician. Do you or your spouse have medical insurance? ■ Medicare ■ Medicaid ■ Private carrier Monthly gross income $_______ Monthly expenses $_______ Disposable income $_______ Choose One Option Only: ____ 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 ____ Polar Cooling Accessory Kit: (hat, neck wrap, wrist wraps) Hat: ■ baseball cap ■ straw - Neck Wrap Style: ■ Fashion Print ■ Solid Color: ■ Blue ■ Khaki ■ Black ■ Pink ____ Steele Classic Cooling Vest Kit: Universally Sized, Color: ■ Blue ■ Tan (includes the vest and 2 sets of 15oz Gel Ice Thermo-strips) ____ Heat Relief Depot Accessory Package: (hat, necktie, wristbands) Hat Size: ■ S ■ M ■ L ■ XL - Color: ■ Navy ■ Khaki ____ Thermapparel Cooling Vest: Size: ■ XS ■ S ■ M ■ L ■ XL ■ 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: MS Focus, 6520 N. Andrews Ave., Fort Lauderdale, FL 33309 COOLING PROGRAM COOLING PROGRAM