I AM ALS Peer Support Initiative: Mentor Application Survey

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

Date of Birth

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

2.Please share your name and contact information below.(Required.)

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

3.What is your connection to ALS? Select all that apply.(Required.)

I have been diagnosed with ALS

I am the primary caregiver for a loved one with ALS

I am a loved one of someone diagnosed with ALS

I lost someone diagnosed with ALS

I do not have a connection to ALS

Other (please specify)