MSAC Membership Application

First Name *

Last Name *

Email *

Phone *

Address 1 *

City *

State/Province *

Zip *

Cell phone carrier *

Birth Date *

// (mm/dd/yyyy)

Date of diagnosis *

Who is your neurologist? *

Tell us about your mobility *

Walk independently
Use a cane
Use a walker
Use a manual wheelchair
Use a scooter
Use a power wheelchair

Are you currently employed? *

Full time
Part time
Not at all

Where do you live? *

Home
Apartment
Assisted living facility
Long term care facility

Who do you live with? *

Alone
Spouse
Family
Friend
Group

Have you seen the MS Achievement Center in person? *

Yes
No

What form of transportation do you plan to use to attend MSAC? *

Self
Family/Friend
Public transportation
Need more information

Please send me an application for reduced fees

Yes please

What interested you about MSAC? *

How did you hear about MSAC? *

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