2023 ALS Clinical Research Learning Institute Application

Application Deadline: June 23, 2023

Thank you for your interest in the ALS Clinical Research Learning Institute® (CRLI). Coordinated by the Northeast Amyotrophic Lateral Sclerosis Consortium® (NEALS), the ALS-CRLI is a two-day program that empowers attendees to be strong advocates in the field of ALS by educating them on clinical research and the therapy development process. Certification as an ALS Research Ambassador® provides opportunities to influence and improve the ALS research process.

The 2023 NEALS CRLI will take place October 3 - 4, 2023 in Clearwater Beach, Florida. People living with ALS, caregivers, and family members residing in North America who have not attended a previous CRLI are encouraged to apply. For more information about the CRLI program, please visit the NEALS website.

People living with ALS who are accepted into the program will be invited to bring one caregiver or family member. NEALS will cover the cost of travel for both participants and a one-night hotel stay.

All applications are due Friday, June 23, 2023. If you have any questions, please contact Christina Smith, NEALS Communications Coordinator, at csmith@neals.org.

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* 1. Contact Information

Name

Street Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. What is your relation to ALS?

I am a person living with ALS

I am a caregiver

I am a family member

Other

Other (please specify)

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* 3. Have you previously attended an ALS Clinical Research Learning Institute?

Yes

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* 4. Please describe why you would like to participate in an ALS Clinical Research Learning Institute and why you think you would make a great ALS Research Ambassador. Tell us about qualifications, experience, and plans for utilizing this training:

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* 5. Applicants are welcome to upload a letter of support from their ALS clinic, a personal recommendation, or other supporting documents here:

Only PDF, DOC, DOCX, PNG, JPG, JPEG, GIF files are supported.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 6. People living with ALS that are selected to attend the October 2023 ALS-CRLI will be invited to bring one caregiver or family member to attend the meeting with them. Please provide contact information for the additional attendee here:

Name

Email Address

Relationship

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* 7. Spots are limited for each CRLI. If you're not selected to attend the October 2023 ALS-CRLI, would you like to be notified about future CRLI opportunities?

Yes