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Home
About
Mobility and Services
Events
Schedule
Gallery
Sponsors
Rodeo
Contact
Retail
Donate
Everyday Giving
Women Caretakers
Driver-Racing Fans-Wins
Mobility And Services Application
Part of our mission is to provide mobility assistance and medical services for individuals living with autoimmune and neuromuscular diseases (in particular for Multiple Sclerosis, ALS (Lou Gehrig’s Disease), Cerebral Palsy, Rheumatoid Arthritis and Parkinson’s Disease). If you or someone you love is in need of assistance, please fill out the application below.
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Applicant Name
Age (photo ID may be requested)
18 and under
19 - 40
41 - 60
61 - 80
81 and up
Home Address
Email
*
How did you hear about Pacing For The Cure? (choices include: harness racing, social media, other)?
Name of the person you are applying for (if other than applicant)
State of Residence:
Relationship to this person
Their Age (photo ID may be requested)
18 and under
19 - 40
41 - 60
61 - 80
81 and up
Which illness is this person requesting assistance? (select one or more: Multiple Sclerosis, ALS, Cerebral Palsy, Rheumatoid Arthritis or Parkinson’s Disease)
Number of years this person has the illness? (Approximate)
0 - 5 years
6 - 15 years
16 - 30 years
31+ years
Is this person currently seeking medical treatment?
Yes
No
Level of Mobility
No Limitation
Active but Some Limitation
Limited Mobility
Needs Full Assistance
Is this person in need of medical equipment or medical services and financially unable to purchase it independently?
Yes, they need financial assistance to purchase medical equipment or medical services.
I am not fully aware of their financial situation but know they are in need of medical equipment or medical services.
I'd like to help out, but not exactly sure how I can help.
If so, what type of equipment or services do they need?
Applicant's Household's Annual Income (proof may be requested)
Any additional information you would like to share
I have read, fully understand, and agree to the above Release of Liability.
*
Yes, I agree
No, I do not agree
Pacing for The Cure Inc. offers no guarantee that your request will be granted. The Equipment is being offered “as is” and with no express or implied warranties of fitness for use. The services are being provided by third parties, not Pacing for The Cure, and thus the Applicant hereby releases and forever discharges Pacing for The Cure, Inc. its members, officers, directors, and employees from and against any claims arising from or related to the services. The following item(s) must be included with your application: (a) Letter(s) from a medical professional specifying the need for the requested Equipment or service(s) for the Applicant. In consideration of the receipt of any medical equipment and/or services provided and /or awarded as a result of this application, Applicant hereby releases and forever discharges Pacing For The Cure, Inc., its members, officers, directors, and employees from and against any and all claims arising from or related to: (a) any alleged malfunction of or defect in the Equipment provided; (b) any allegation that the Equipment was not appropriate or suitable for the Applicant; (c) any other matter, of any type related, in any way, to the Applicant’s receipt or use of the Services or Equipment.
Comment
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