Support Group Registration Form

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Question - Required - What is your connection to ALS? (Select all that apply)
Please make between 1 and 5 selections from the choices below.

   


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Registration Information:

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Name:

 

 

   

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City/State/ZIP:

 

    

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GUIDELINES

Confidentiality:


* Facilitators will not give out attendess’ contact information to other attendess 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.

 

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   Please leave this field empty