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2018 Client Application - NCT Service MS Day in Asheville

 

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 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 any questions, please do not hesitate to call (800) 344-4867, ext 51126.

Be sure to return the signed waiver and release form for you and each adult in your household. 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.

  Service MS Application

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Date of Birth:

 

 

 

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