Multiple Sclerosis Foundation - Assistive Technology Form

Get Educated
What is MS?

A chronic neurological disorder that affects the central nervous system, comprised of the brain...
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Donate
Get Help
Health & Wellness Program

Get educational materials and referrals, as well as the opportunity to participate in various...
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Get Involved
MS Awareness Month

An annual, nationwide campaign with goals to promote an understanding of MS, and to assist those...
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Events
MS Focus on Fashion

The inaugural MS Focus on Fashion, will take place on Nov. 6, in Dania Beach, Fla.
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About Us
Programs & Grants

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Homecare Assistance Grant Through the Homecare Assistance Grant, MS Focus provides homecare, caregiver respite, and... /Get-Help/MSF-Programs-Grants/Homecare-Assistance-Grant

Date of Birth (mm/dd/yyyy):

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

Now

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

What type of equipment do you have now?:

What additional equipment do you need?:

Are you employed?:

Yes
No

Spouse employed?:

Yes
No

Monthly Gross Income (Less Witholding Taxes)

Monthly Expenses

Mortgage or Rent:

Enter security code: