*1.Thank you for your interest in volunteering as an I AM ALS Peer Support Specialist! Before we get started, please introduce yourself.(Required.)

First Name

Last Name

Birth Date (MM/DD/YYYY)

Email

Phone

*2.What is your preferred method of communication?(Required.)

Phone

Email

*3.What is your connection to ALS? Please select all that apply.(Required.)

I have been diagnosed with ALS

I may have ALS

I am the primary caregiver for a loved one diagnosed with ALS

I am a loved one of someone diagnosed with ALS

I lost someone diagnosed with ALS

I am an ALS gene carrier

I am an ALS healthcare professional

I do not have a connection to ALS

My connection is not listed (please specify)

Other (please specify)

*4.What is your relationship to the person diagnosed with ALS?(Required.)

Self

I am their spouse or domestic partner

I am their parent

I am their sibling

I am their adult child

I am their friend

I am their paid caregiver

Other (please specify)