I AM ALS Peer Support Specialist Application

First Name

Last Name

Birth Date (MM/DD/YYYY)

Phone

Phone

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)

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)