MS Story Bank Submission Form
Exit this survey
1. Default Section
Are you a person living with MS -- or a friend, family member or caregiver? We want to hear your MS story! Share your story now...
1
. I am a:
I am a:
Person living with MS
Family member of a person living with MS
Friend of a person living with MS
Other (please specify)
*
2
. How would you like to be identified in your MS story?
How would you like to be identified in your MS story?
Please use my first and last name.
Please use my first name only.
Please use a false name.
3
. Please tell us about yourself:
Please tell us about yourself:
First name
Last name
Age
City
State
Month of diagnosis
Year of diagnosis
Age at diagnosis
4
. Contact information:
Contact information:
Home phone
Cell phone
E-mail
5
. What is your preferred contact method?
What is your preferred contact method?
Home phone
Cell phone
E-mail
6
. Tell us your MS story!
Not sure what to say? Here are some questions that might help get you started:
> How did you find out you had MS?
> How has MS changed your life?
> How has National MS Society helped you?
> How does MS impact your family, work, insurance and/or finances?
> What activities are most difficult with MS?
> What activities are you most proud of?
Tell us your MS story! Not sure what to say? Here are some questions that might help get you started: > How did you find out you had MS? > How has MS changed your life? > How has National MS Society helped you? > How does MS impact your family, work, insurance and/or finances? > What activities are most difficult with MS? > What activities are you most proud of?
7
. More to say? Continue below!
More to say? Continue below!
8
. Even more to say? Continue here!
Even more to say? Continue here!
*
9
. I hereby grant permission to the National Multiple Sclerosis Society and the Mid-Atlantic Chapter the right to use, reuse, publish and republish my name, voice, likeness, and/or other indicia of identity, in any medium now known or hereafter developed including any print or digital usage for promotional material or publication, alone or in conjunction with other material, without restriction as to changes or alterations, for editorial, educational, promotional and advertising purposes, including without limitation in connection with the solicitation of contributions and the furtherance of the corporate objectives of the Society, and to use biographical and other information about me in conjunction therewith.
I hereby grant permission to the National Multiple Sclerosis Society and the Mid-Atlantic Chapter the right to use, reuse, publish and republish my name, voice, likeness, and/or other indicia of identity, in any medium now known or hereafter developed including any print or digital usage for promotional material or publication, alone or in conjunction with other material, without restriction as to changes or alterations, for editorial, educational, promotional and advertising purposes, including without limitation in connection with the solicitation of contributions and the furtherance of the corporate objectives of the Society, and to use biographical and other information about me in conjunction therewith.
I agree
I DO NOT agree
Please e-mail a digital photo to KRISTYN.EDWARDS@NMSS.ORG.
Thank you for helping us move closer to a world free of MS!
Powered by
SurveyMonkey
Create your own
free online survey
now!
Javascript is required for this site to function, please enable.