Multiple Sclerosis Foundation - Computer Program Form

Date of Birth (mm/dd/yyyy):

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

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?:

Computer Preference:

DesktopLaptopUpgradesTraining

Computer Use:

PersonalFamily UseResearchBusiness

Do you own a computer?:

YesNo

Do you know how to operate a computer?:

YesNo

Are you employed?:

Yes
No

Spouse employed?:

Yes
No

Mortgage or Rent:

MortgageRent

Enter security code: