Mobility Aid Application
Part of our mission is to provide mobility assistance equipment for survivors, regardless of their current limitations. Mobility is imperative because it allows us to continue doing what we love to do. It is our desire to keep as many MS warriors on the move with the appropriate mobility aid. If you or someone you love is in need of assistance due to MS, please fill out the application below.
Applicant Name:
Your answer
Age (photo ID may be requested):
Home Address:
Your answer
E-mail Address:
Your answer
What is your connection to harness racing?
Your answer
How many year have you been involved in harness racing?
Name of the person you are applying for (if other than applicant):
Your answer
State of Residence:
Your answer
Relationship to this person:
Your answer
Their Age (photo ID may be requested):
Does/Did this person work in the harness racing community?
Your answer
(Approximate) Number of years this person has struggled with MS?
Is this person currently seeking medical treatment?
Your answer
Level of Mobility:
Is this person in need of medical equipment and is financially unable to purchase it independently?
If so, what type of equipment do they need?
Your answer
Applicant's Household's Annual Income (proof may be requested):
Your answer
Applicant hereby certifies the accurateness of the above information.
Any additional information you would like to share:
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms