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NCT Service Project Client Application 2012.13

1. Please enter your information below or log-in

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Name:

 

 

   

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City/State/ZIP:

 

    

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What's this?

*2.
Question - Required - What is your relationship to MS?


*3.
Question - Required - Please note that we can only pilot the cities below within a 10 mile radius. Tell us what city you live within 10 miles.





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*5.
Question - Required - Tell us about your pets.
Please make between 1 and 6 selections from the choices below.

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Question - Required - Services
Please make between 1 and 3 selections from the choices below.

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Question - Required - I have difficulty with these tasks due to: (check all that apply):
Please make between 1 and 6 selections from the choices below.

 

Client Responsibility

I understand and agree to the following conditions.

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WAIVER AND RELEASE FROM LIABILITY
What a Difference a Day Makes: Service Day

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Question - Required - In consideration for my participation in the What a Difference a Day Makes: Service Day program, I freely accept and voluntarily assume the risks of personal injury or property damage that may arise as a result of my participation. I further agree to release and hold the Society, its directors, officers, employees, agents and chapters harmless from any and all claims and demands arising out of or in connection with my participation in the Program. By marking yes, I have read the foregoing and fully understand and agree to the contents thereof.


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