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 with another household member, if you are not available?YesNo Please include a written confirmation of diagnosis of MS from your physician. Do you or your spouse have medical insurance? MedicareMedicaidPrivate carrier Monthly gross income $________ Monthly expenses $________ Disposable income $_________ What would a cooling garment allow you to do that you are unable to do or have difficulty doing now?___________________________________________________________________________ Choose One Option Only: ___ Polar Fashion Cooling Vest Kit: (vest, neck wrap, hat) Female VestMale Vest - Size:XS S MLXL 2XL 3XL 4XLColor:BlackKhakiLight BluePink 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 PrintOrange 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 allExtreme 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 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'