Support Group Registration Form * Question - Required - What is your connection to ALS? (Select all that apply) Please make between 1 and 5 selections from the choices below. Person living with ALS Spouse/Partner Family Member Surviving Family Member Caregiver Other Question - Not Required - If you selected, Spouse/Partner, Family Member or Caregiver from the list above, please share with us the name of the person with ALS in your life: * Question - Required - Please tell us which Les Turner ALS Foundation Support Group you plan on attending: Please select response Barrington (Second Saturday from 10:30am 12:30pm) Chicagoland Area (Third Tuesday from 1 - 2:30pm) Rooney Family Memorial Support Group - Far South Side (First Thursday of from 6:30 8pm) Wheaton (Fourth Saturday from 10:30am - 12:00pm) Moving Forward After Loss - Bereavement Group (Closed Group, Invitation Only) Living After Loss - Bereavement Group (Closed Group, Invitation Only) Confidentiality: * The Les Turner ALS Foundation group facilitators will never give out your information--even to another group member--without your permission. We encourage you, as a group member, to follow this rule as well. * I will not share patient/family names or other identifying information with people outside of the group. * I will not solicit for anything that is not Foundation-related, e.g. an offer to join your Walk team is okay, but a request to buy something you're selling is not okay. Photo Release: * Question - Required - *I grant full permission for the Les Turner ALS Foundation to use photographs, or video recordings, or any other record of this event in which I may appear for any educational or fundraising purposes. Please select response Yes No Registration Information: (Required) * Name: First Required Last Required * Email: Required * Phone Number: Required Yes, I would like to receive e-mail from Les Turner ALS Foundation Yes, I would like to receive postal mail from Les Turner ALS Foundation * Question - Required - I agree to the support group goals, guidelines and confidentiality outlined above: Please select response Yes No Spam Control Text: Please leave this field empty