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?:

Please include a written confirmation of diagnosis of MS from your physician.

What type of transportation do you have now?:

This grant assists with paratransit fees, minor car repairs, and funds transportation toand from neurologist appointment, infusion centers or MS centers, allowing those with MS to seek treatment.

What type of transportation assistance are you requesting?:

Paratransit feesMinor vehicle repairLyftOther, please explain:

Describe any current family/friends support:

Complete this section only if requesting transportation from Lyft.

What is your Lyft transportation assistance for?:

Neurologist appointmentInfusion CenterMS Center

In order to qualify for this transportation, you must be able to transfer and get in andout of a vehicle independently, or must be accompanied by a care partner who canassist you in transferring.
All mobility aids must fit in a standard car trunk.
In order to qualify for this transportation, you must have access to a cell phone whichcan send and receive text messages.
This transportation is only available to and from a MS Center, neurologist’s office orinfusion center.

Can you transfer and get in and out of a vehicle independently?:

YesNo

If no, will a care partner accompany you?:

YesNo

Can you send and receive text messages?:

YesNo

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.:

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