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 Sent:
Date Received:
Checklist:
Verification:
MSSP Office USE ONLY
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Sheila’s Gift
Grant Request Form
Child’s Name: _______________________________________________________
Parent’s Name(s): _______________________________________________________
Address:
 _______________________________________________________
City: ____________________
  State:____________________  Zip:____________________
Telephone, Home: ____________________
 Work:____________________ Cell:____________________
Size of Household: _______________________
 Ages of children: _______________________
Person Submitting Request: _______________________ Relationship to child: _______________________
Best time to reach you:
 _______________________
 Telephone: _______________________
Describe Financial Request: (In 500 words or less – please continue on backside)
Grants are made payable to the parent on behalf of the child
($250 max per child -- $500 per family)
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Amount/Purpose/Date/Funds Needed
Amount: $_____________  Purpose: _____________________________________  Needed By: _________________
Application Checklist:
Completed Application                  Utility Bill                  Evidence of (Parents) MS Diagnosis

Application Submitted By :______________________________________________________ Date:__________
                                         Signature Required

Send completed applications to:

MSSP, Sheila's Gift
2901 SE 122nd Ave.
Portland, OR 97236
or by FAX: 503-297-6264
DEADLINE: Must be postmarked by 11/30/08