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2022 SoCal Ride and Rally to Defeat ALS Zoom Registration
1.
Please fill in your personal information.
*
Name:
First
Required
Last
Required
*
Email:
Required
Phone Number:
Yes, I would like to receive important updates about this event from the Golden West Chapter
*
2.
Question - Required -
What is your ALS connection?
Select
I am a person with ALS
I am a friend or loved one of a person with ALS
I am a healthcare provider for people with ALS
I am affiliated with an organization that serves the ALS community
Other
*
3.
Question - Required -
Are you registered for the 2022 SoCal Ride and Rally to Defeat ALS?
Select
Yes
No
4.
Question - Not Required -
If yes to #3, list your team here:
5.
Question - Not Required -
If no to #3, would you like us to register you? If yes, please list a team affiliation if any.
6.
Question - Not Required -
Do you have any questions or comments that you would like to share with us prior to the May 14th event? (Upon request, we will get back to you as soon as possible.)
(Maximum response 255 chars, approx. 5 rows of text)
Spam Control Text:
Please leave this field empty
2022 SoCal Ride and Rally to Defeat ALS Zoom Registration
1.
Please fill in your personal information.
*
Name:
First
Required
Last
Required
*
Email:
Required
Phone Number:
Yes, I would like to receive important updates about this event from the Golden West Chapter
*
2.
Question - Required -
What is your ALS connection?
Select
I am a person with ALS
I am a friend or loved one of a person with ALS
I am a healthcare provider for people with ALS
I am affiliated with an organization that serves the ALS community
Other
*
3.
Question - Required -
Are you registered for the 2022 SoCal Ride and Rally to Defeat ALS?
Select
Yes
No
4.
Question - Not Required -
If yes to #3, list your team here:
5.
Question - Not Required -
If no to #3, would you like us to register you? If yes, please list a team affiliation if any.
6.
Question - Not Required -
Do you have any questions or comments that you would like to share with us prior to the May 14th event? (Upon request, we will get back to you as soon as possible.)
(Maximum response 255 chars, approx. 5 rows of text)
Spam Control Text:
Please leave this field empty
