*1.

Question - Required - What is your connection to ALS?

*2.

Question - Required - Why do YOU participate in the EVENT TYPE to Defeat ALS? The purpose of this question is for you to share your story. Please be as detailed as you can. (i.e. When were you or your loved one diagnosed? How has ALS affected your and/or their daily life? What are some details about your experience with ALS that you'd like to share with others? Share a story about your loved one / you.)

3.

Question - Not Required - Has The ALS Association helped you or someone you know? If so, how? (i.e. support groups, care services, community outreach event, access to clinical trial or equipment loan, etc.)

*4.

Question - Required - What has ALS taken away from you, and what has it brought into your life?

*5.

Question - Required - Are you OK with your story being shared with others to help us raise awareness for ALS? We will work with you and confirm your approval before we distribute any communication.

6.

Please enter some information about yourself in the fields below:

*

Name:

Title	First Required	Middle Required	Last Required	Suffix

*

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Country:

Phone Number:

Yes, I would like to receive e-mails from the Golden West Chapter.

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We appreciate your participation in the EVENT and all you are doing to raise awareness and support for the ALS community!

Share your story TEMPLATE

We appreciate your participation in the EVENT and all you are doing to raise awareness and support for the ALS community!

Share your story TEMPLATE

We appreciate your participation in the EVENT and all you are doing to raise awareness and support for the ALS community!