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Thank you for your interest in becoming a Mentor to people affected by ALS! All information shared through this application will be kept confidential, and will not be shared without your explicit consent. 

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* 1. Please share your birth date to confirm that you are 18 years of age or older. 


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* 2. What is your connection to ALS? Select all that apply.

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* 3. What is your relationship to the person diagnosed with ALS?

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