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2022 Major Donor Story

*1.

Question - Required - What is your connection to ALS?

I am a person with ALS

I am the spouse or partner of someone who has or had ALS

I am the child of someone with ALS

I am the parent of someone with ALS

I am the family member of someone with ALS

I have a friend or work with someone with ALS

I am a care provider who cares for people with ALS

I am a researcher who is studying ALS

I am a person who supports the ALS community and the fight to defeat ALS

*2.

Question - Required - Tell us some general information about yourself and/or your loved one. The purpose of this is to show what your life was like before ALS became a part of it. (Examples: Where are you from? Where did you go to school? Where did you meet your significant other? What kind of work do you do? Did you volunteer with other organizations before? )

*3.

Question - Required - If you are a person with ALS or one of their loved ones, please enter the age and the date of the diagnosis.

*4.

Question - Required - Tell us more about yourself and/or your loved one. (What were the first symptoms? Where are you receiving your care? How has ALS affected your daily life? When did you start volunteering? etc) :

*5.

Question - Required - What are some important details about your experiences with ALS that you would want the general public to know about?

*6.

Question - Required - What are some of the ways that you have been participating with the ALS community and with The ALS Association Golden West Chapter. This could include activities like attendance at support groups, participation in community outreach events, receiving care or participating in a clinical trial at an Association-supported clinic or center, following us on social media, being an ALS advocate, and more.

*7.

Question - Required - Why have you chosen to support the Golden West Chapter with a significant gift?

8.

Question - Not Required - Did you give through your retirement account, DAF, or other planned giving vehicle? What would you like the public to know about these types of giving options?

*9.

Question - Required - If there was "one thing" that you would like to share about your experiences with ALS and as a part of the ALS community with the general public, what would it be?

*10.

Question - Required - MEDIA RELEASE: By participating in this project, I hereby give my consent for The ALS Association Golden West Chapter for the following: 1. To use my comments, photos, and story in their public awareness campaigns. 2. To use my likeness in still photographs for media and awareness use which may include newsletters, articles, website posting and other such materials. My recompense for this effort is the satisfaction of helping others learn about ALS, the work of The ALS Association and the Golden West Chapter, and the personal enjoyment of participation in a worthwhile project to raise awareness about the disease. I acknowledge that I own the copyright to the images that I am submitting or that I have obtained the written permission of the copyright owner.

11.

Please enter some information about yourself in the fields below: (For proper photo credit and release of information)

*

Name:

Title	First Required	Middle Required	Last Required	Suffix

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

Country:

Phone Number:

If you respond and have not already registered, you will receive periodic updates and communications from The ALS Association.

Keep me logged in. What's this?

Remembers your login information for your convenience. Use only on trusted, private computers.

Thank you for sharing your ALS story!

Spam Control Text: Please leave this field empty

2022 Major Donor Story

*1.

Question - Required - What is your connection to ALS?

I am a person with ALS

I am the spouse or partner of someone who has or had ALS

I am the child of someone with ALS

I am the parent of someone with ALS

I am the family member of someone with ALS

I have a friend or work with someone with ALS

I am a care provider who cares for people with ALS

I am a researcher who is studying ALS

I am a person who supports the ALS community and the fight to defeat ALS

*2.

Question - Required - Tell us some general information about yourself and/or your loved one. The purpose of this is to show what your life was like before ALS became a part of it. (Examples: Where are you from? Where did you go to school? Where did you meet your significant other? What kind of work do you do? Did you volunteer with other organizations before? )

*3.

Question - Required - If you are a person with ALS or one of their loved ones, please enter the age and the date of the diagnosis.

*4.

Question - Required - Tell us more about yourself and/or your loved one. (What were the first symptoms? Where are you receiving your care? How has ALS affected your daily life? When did you start volunteering? etc) :

*5.

Question - Required - What are some important details about your experiences with ALS that you would want the general public to know about?

*6.

Question - Required - What are some of the ways that you have been participating with the ALS community and with The ALS Association Golden West Chapter. This could include activities like attendance at support groups, participation in community outreach events, receiving care or participating in a clinical trial at an Association-supported clinic or center, following us on social media, being an ALS advocate, and more.

*7.

Question - Required - Why have you chosen to support the Golden West Chapter with a significant gift?

8.

Question - Not Required - Did you give through your retirement account, DAF, or other planned giving vehicle? What would you like the public to know about these types of giving options?

*9.

Question - Required - If there was "one thing" that you would like to share about your experiences with ALS and as a part of the ALS community with the general public, what would it be?

*10.

Question - Required - MEDIA RELEASE: By participating in this project, I hereby give my consent for The ALS Association Golden West Chapter for the following: 1. To use my comments, photos, and story in their public awareness campaigns. 2. To use my likeness in still photographs for media and awareness use which may include newsletters, articles, website posting and other such materials. My recompense for this effort is the satisfaction of helping others learn about ALS, the work of The ALS Association and the Golden West Chapter, and the personal enjoyment of participation in a worthwhile project to raise awareness about the disease. I acknowledge that I own the copyright to the images that I am submitting or that I have obtained the written permission of the copyright owner.

11.

Please enter some information about yourself in the fields below: (For proper photo credit and release of information)

*

Name:

Title	First Required	Middle Required	Last Required	Suffix

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

Country:

Phone Number:

If you respond and have not already registered, you will receive periodic updates and communications from The ALS Association.

Keep me logged in. What's this?

Remembers your login information for your convenience. Use only on trusted, private computers.

Thank you for sharing your ALS story!

Spam Control Text: Please leave this field empty

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The ALS Association Golden West Chapter

California Mailing Address - PO Box 7082, Woodland Hills, CA 91365.

Hawaii Mailing Address - PO Box 11284, Honolulu, HI 96828

(866)-750-2572 (ALSA)

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