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NCT Service MS: What a Difference a Day Makes Application

 

Thank you for your interest in Service MS:  What a Difference a Day Makes, the chapter’s  service project program for people living with MS.  Please note that all information provided is confidential and will not be released without prior consent.  The following items are required in order to review your request. 

In order to participate, you will need to complete and return the following:

  • Completed Application
  • Confirmation of your diagnosis of MS (if not previously provided). This could include a letter from your doctor, a copy of a medical record noting MS diagnosis, or a copy of a prescription for your MS disease-modifying therapy. 
  • Waiver of responsibility – Signed by each member of the household. 
  • Signed Client Bill of Rights

Please complete the application form and note your choice of services with which you would like assistance.  If you need assistance completing any of the paperwork or have queestions, please call the chapter office at 1-800-344-4867, extension 51224.   

Be sure that each member of your household sign the waiver and release form.  If a child will be present on the Service MS day, please complete the minor waiver for each child. 

All requests are reviewed on a case by case basis in accordance with Society-wide principles, standards, and chapter policies.  While we wish we could assist every person in need, please know that our resources and volunteers are limited. 

 Please return all forms to:

 National MS Society

Attn: Constance McClary

3101 Industrial Dr. Ste 210

Raleigh, NC 27609

Email:  constance.mcclary@nmss.org

 

PLEASE NOTE:  We will work to recruit a Service MS volunteer team as soon as possible. You will be contacted within 48 hours to confirm receipt.  

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?

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Question - Required - What is your relationship to MS?


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Question - Required - Please check your city (within 25 miles of the city center)











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Question - Required - Please tell us what services you need assistance with.
Please make 3 selections from the choices below.

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Client Responsibility

I understand and agree to the following conditions.

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NATIONAL MS SOCIETY - CLIENT BILL OF RIGHTS

•  The right to receive considerable and respectful care in the home, to be treated with dignity and respect, to have property treated with respect, and to expect that Independence Assistance (IAs), within the limits of the service contract, will respond in good faith to the client’s request for assistance in the home.
•  The right to participate in planning services to be provided. A written service plan/contract will be jointly developed.
•  The right to receive information and referrals about community services and organizations which might empower the client to live in a more independent manner, and for the purpose of improving the quality of life for the client.
•  The right to receive the name of the supervisor and the MS chapter’s telephone number.
•  The right to refuse recommended services.
•  The right to be informed fully about the expected consequences of care.
•  The right to receive information on the National MS Society’s policies and procedures, including information about qualifications and supervision of IAs, and on discontinuation of service.
•  The right to express complaints about services that are (or fail to be) furnished, and to be able to express complaints without fear of being discriminated against or otherwise harmed as a result of having complained.
•  The right to request a change of caregiver.
•  The right to confidentiality of client records and information.
•  The right to privacy.
•  The right to be informed fully, in writing before care begins, of these rights.
•  The right to be informed of the way to voice grievances about service.
•  The right to know about the National MS Society has liability insurance coverage.
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Waiver of Responsibility - Service MS

For consideration of participation in the Service MS: What a Difference a Day Makes program, I, waive and release the National Multiple Sclerosis Society (“Society”), its chapters, directors, officers, administrators, representatives and executors, past and present employees, volunteers, agents, supervisors, participants, all state and local governments, assigns, all sponsors, their representatives and successors and other persons(collectively, the “Releasees”), from any and all claims, liabilities, or causes of action arising out of an injury to me (or my child) and from any and all claims, liabilities, or causes of action arising from my (or my child’s) participation or attendance in this event.

EMERGENCY MEDICAL TREATMENT AUTHORIZATION:  I hereby authorize the National Multiple Sclerosis Society to seek emergency medical treatment for the below mentioned individual(s), who will be participating. 

CONFIDENTIALITY AGREEMENT:  To the degree that I may be given access to the identity and details of persons with multiple sclerosis and their families, I will safeguard such information in strict confidence.

PHOTOGRAPHY/MEDIA RELEASE

I hereby grant full permission to Society to use, reuse, reproduce, publish, or republish any photographs, motion pictures, recordings, or any other record of my participation in this event, including all Society sponsored pre and post event activities, in any medium now known or hereafter developed, alone or in conjunction with other material, without restriction as to changes or alterations, as well as to use my name, voice, likeness, and/or other indicia of identity, for editorial, educational, promotional, advertising, and commercial purposes, including without limitation in connection with the solicitation of contributions and the furtherance of the corporate objectives of Society. Further, I relinquish all rights, title, and interest in any and all photographs, motion pictures, recordings, or other records of Service MS: What a Difference a Day Makes I may take or capture to Society.

 

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