Survey - 2023 California ALS Research Summit Registration

1.

Please enter your personal contact information here:

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Name:

First Required	Last Required	Professional Suffix

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Email: Required

Street 1:

City/State/ZIP:

City	State	ZIP

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Phone Number: Required

Yes, I would like to receive e-mail updates about the California ALS Research Summit and other important news updates from The ALS Association Golden West Chapter.

*2.

Question - Required - Institution/Affiliation:

*3.

Question - Required - Name and title as it should appear on badge:

(Maximum response 255 chars, approx. 5 rows of text)

*4.

Question - Required - Do you have an administrative assistant that we can contact if necessary? (If yes, please enter their name, telephone, and email address. If no, please enter "does not apply")

(Maximum response 255 chars, approx. 5 rows of text)

5.

Question - Not Required - Which of the following events will you be attending?

*6.

Question - Required - RSVP for the Golden West Chapter's Champions for Cures and Care celebration honoring the California ALS Research Network on Friday evening, January 20, 2023. Will you join us? (All registered Research Summit attendees receive one complimentary admission for cocktails and dinner on January 20. Those who are attending the WALS meetings only may be required to purchase tickets.) Companies and institutions are also strongly encouraged to become a sponsor of this special event. For more information about sponsorship levels, additional tickets, and tribute book ads, please contact Asher Garfinkel at agarfinkel@alsagoldenwest.org and visit alschampions.org.

7.

Question - Not Required - Please list if you have any special dietary or accessibility needs:

*8.

Question - Required - What method of transportation are you planning to use to get to/from the conference?

*9.

Question - Required - Where will you be staying?

*10.

Question - Required - Please list your arrival and departure dates below

*11.

Question - Required - Are you an early-career researcher interested in participating in the Barber ALS Research Award Poster Presentation?

12.

Question - Not Required - In your opinion, what were the 1-2 most significant clinical or basic science publications in ALS/MND over this past year?

(Maximum response 255 chars, approx. 5 rows of text)

13.

Question - Not Required - Any additional comments or questions for the summit organizers?

(Maximum response 255 chars, approx. 5 rows of text)