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 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 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: (vest,neck wrap, hat) ■ Female Vest ■ Male Vest - Size: ■ XS ■ S ■ M ■ L ■ XL ■ 2XL ■ 3XL ■ 4XL Color: ■ Black ■ Khaki ■ Light Blue ■ Pink Cooling Pack: ■ Kool Max Water-Based Cooling Pack ■ Cool58 Phase Change 58 Degree F Phase Hat: (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/L ■ L/XL ___ Thermapparel Cooling Vest: Size: ■ XS ■ S ■ M ■ L ■ XL Color: ■ 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 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