Survey - Support Group Registration Form - Les Turner ALS Foundation

Support Group Registration Form

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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:

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Question - Required - Please tell us which Les Turner ALS Foundation Support Group you plan on attending:

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:

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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.

Registration Information:

(Required)

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Name:

First Required	Last Required

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Email: Required

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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

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Question - Required - I agree to the support group goals, guidelines and confidentiality outlined above: