Support Group Registration Form Field Is Required What is your connection to ALS? (Select all that apply) Please make between 1 and 5 selections from the choices below. Person living with ALS Spouse/Partner Family Member Surviving Family Member Caregiver Other If you selected Spouse/Partner, Family Member, Surviving Family Member, Caregiver or Other from the list above, please share with us the name of the person with ALS: Field Is Required Please tell us which Les Turner ALS Foundation Support Group you plan on attending: Please select response Newly Diagnosed Support Group (First Tuesdays from 6 - 7pm) Navigating ALS Together (Second Saturdays from 10:30am - 12pm) Navigating ALS Together (Third Mondays from 2 - 3:15pm) Navigating ALS Together (Fourth Saturdays from 10:30 - 11:30am) ALS Caregivers Support Group (Third Mondays from 3:30 - 4:30pm) ALS Caregivers Support Group (Third Thursdays from 3 - 4pm) ALS Caregivers Support Group (Third Thursdays from 7 - 8pm) Young Adult Support Group (Third Tuesdays from 7 - 8pm) Moving Forward After Loss - Spouse/Partner (Select Thursdays, 6 - 7:30pm) Living After Loss (Fourth Mondays from 6 - 7:30pm) Young Adult Bereavement (Third Wednesdays from 6 - 7:30pm) Registration Information (required) Name: Field Is Required First Field Is Required Last Address: Field Is Required Street 1: Street 2: City/Town: Field Is Required City/Town: State / Province: Field Is Required State / Province: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AS FM GU MH MP PR PW VI AA AE AP AB BC MB NB NL NS NT NU ON PE QC SK YT None Required ZIP / Postal Code: Field Is Required ZIP / Postal Code: Email: Field Is Required Email: Phone Number: Field Is Required Phone Number: Yes, I would like to receive email. Yes, I would like to receive postal mail. Guidelines Confidentiality: Facilitators will not give out attendees’ contact information to other attendees without verbal or written permission. It is suggested that group members following this rule as well. I will not share patient/family names or other identifying information with people outside of the group. I will not solicit for anything that is not Foundation-related, e.g. an offer to join your Walk team is okay, but a request to buy something you're selling is not okay. Respect: I will be courteous when others are speaking and will not interrupt. I will not criticize, blame, or shame other group members based on their comments. I will use "I" statements to reflect my opinions, experiences and feelings. Participation: I will do my best to attend the group on a consistent basis so I can experience the greatest benefit of the group through my attendance and participation, while also supporting others. Permission: I grant full permission for the Les Turner ALS Foundation to use photographs, or video recordings, or any other record of this event in which I may appear for any educational or fundraising purposes. Field Is Required I agree to the confidentiality, respect, participation and permissions outlined above: Please select response Yes No (required) Spam Control Text: Please leave this field empty
