b'CCOOOOLLIINNGGPPRROOGGRRAAMMQUALIFICATION APPLICATION(Please Print)Last Name __________________________________ First Name___________________________Street (no PO boxes)_______________________________________________Apt. ___________City ____________________________ County ______________ State ________ Zip __________Phone ________________________Email ________________________ Date of Birth _________AlternateContact__________________________________________________________________Relationship _________________________________________ Phone ______________________Physicians Name __________________________________________________________________Physicians 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 withanother household member, if you are not available? YesNoPlease include a written confirmation of diagnosis of MS from your physician.Do you or your spouse have medical insurance?MedicareMedicaidPrivate carrierMonthly gross income $________ Monthly expenses $________ Disposable income $_________Choose One Option Only:___ Polar Fashion Cooling Vest Kit: (vest,neck wrap, hat)Female VestMale Vest - Size:XS S M LXL2XL 3XL4XL Color:BlackKhakiLight BluePinkCooling Pack:Kool Max Water-Based Cooling Pack Cool58 Phase Change 58 Degree F PhaseHat: (Circle color) Bucket Hat (Blue, Khaki, Lt. Blue) Baseball Cap (Black, Blue, Khaki, Lt. Blue, Pink) Straw Hat.___ Polar Cooling Accessory Kit: (hat, neck wrap, wrist wraps) Hat: (Circle color) Bucket Hat (Blue, Khaki, Lt. Blue) Baseball Cap (Black, Blue, Khaki, Lt. Blue, Pink) Straw Hat.Neck Wrap Color: Black Blue Khaki Light Blue Pink Pink Print Orange Multi Print Superhero Print Starry Night Print Turquoise Print ___ Heat Relief Depot Accessory Package: (hat, necktie, wristbands) Extreme Condition Hat Kit 1: Khaki, one size fits all Extreme Adventure Hat Kit 2: Navy,Size:M/LL/XL___ Thermapparel Cooling Vest: Size:XS S M L XLColor: Black White___ Steele Classic Cooling Vest Kit: (vest and 2 sets of 15oz Gel Ice Thermo-strips) Universally Sized, Color:Blue Tan I hereby release and hold the Multiple Sclerosis Foundation, Inc. harmless from, against, and in respect ofall claims, injuries, actions, demands, suits, losses, liability or other damages that may be incurred as a resultof accepting goods or services.Applicant Signature: _________________________________________Date: ___________Send your completed application to:The Multiple Sclerosis Foundation, 6520 N. Andrews Ave., Fort Lauderdale, FL 33309'