Survey - Chapter Services Quick Registration - The ALS Association Western Pennsylvania Chapter

Chapter Services Quick Registration

Please fill out the following information so that we can begin to serve you. A member of our Care Services staff will be in touch within the next two business days with more information and to answer your questions.

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Question - Required - Have you been diagnosed with any of the following by a physician?: ALS, PLS, PBP, or PMA

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Question - Not Required - Are you currently receiving Social Security Disability benefits?

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Question - Required - I would like more information about (select all that apply)...
Please make between 1 and 10 selections from the choices below.

	Veterans Benefits
	In-home Care
	Social Security Disability
	Respite Care
	Transportation
	Assistive Communication Devices
	Equipment/Loan Closet
	Resource/Support Groups
	Multidisciplinary Clinics
	Nutrition/Supplements

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The ALS Association Western Pennsylvania Chapter

416 Lincoln Avenue - Pittsburgh, PA 15209

(412) 821-3254

Lou Gehrig® used with permission of the Rip Van Winkle Foundation / www.LouGehrig.com