Multiple Sclerosis Society of Portland, OR, Inc.
2901 SE 122nd Ave.
Portland, OR 97236
Phone: 503-297-9544
Fax: 503-297-6264
Email: candycehayes@msoregon.org


Date Received:
Dr's Note:
Date Sent:

MSSP Office USE ONLY
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Spring 2010  Deadline: June 30, 2010
Summer 2010 Deadline: August 1, 2010
MSSP 2010  "Summer Comfort"  Application

Name______________________________________________________________________

Address ____________________________________________________________________
               Street                                                                           City                   State                                        Zip

Telephone  __________________________________________________________________

Email Address _______________________________________________________________


1. Do you currently receive our newsletter?
                   Yes [  ]    No [  ] 
                   If No, check here to be added to our mailing list? [  ]
Please select delivery method:
         US MAIL [  ]     PDF by Email [  ]


2. When and where were you diagnosed with MS? _________________________________

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3. How did you hear about this program?
[  ] Newsletter
 [  ] Website
[  ] Telephone Book
 [  ] Support Group
[  ] TV/Radio News Program
[  ] Word of Mouth
[  ] Your Doctor’s Office
 [  ] Other ____________________________

4. Comments: ________________________________________________________________

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Don’t forget to "include" verification of your diagnosis!