Survey - Support Group Registration Form - Les Turner ALS Foundation

*

Question - 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

Question - Not Required - 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:

*

Question - Required - Please tell us which Les Turner ALS Foundation Support Group you plan on attending:

Registration Information:

(Required)

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

Yes, I would like to receive e-mail from Les Turner ALS Foundation

Yes, I would like to receive postal mail from Les Turner ALS Foundation

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.

*

Question - Required - I agree to the confidentiality, respect, participation and permissions outlined above:

Support Group Registration Form

Les Turner ALS Foundation

Accreditation

Affiliates

Site Credit