Register with Our Chapter

*Indicates a required field

Name of Person with ALS
*

Date of Birth
*

Address
*

Address Line 2

City, State
*

Zip
*

Phone Number
*

Select Number Type (required)
CellHomeWork

Email
*

Neurologist or ALS Clinic

Diagnosis Date [If you don't remember the exact date, select the 1st of the month you were diagnosed]

Employer/Retired from

Did you serve in the military? (required)
YesNo

What is your race/ethnicity? For statistical and research purposes only.
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific Islander WhiteOtherPrefer not to answer

Select Insurance Provider
MedicareMedicaidVAPrivate InsuranceN/A

We offer support for children. youth, and young adults. Do you have any children/grandchildren/etc. ages 5 - 30 years old?
YesNo

Are you interested in learning more about the Walk to Defeat ALS?
YesNot Right NowNo

Primary Contact for Patient

Name

Relationship

City

Phone Number

Select Number Type
CellHomeWork

Email

Employer

Additional Information (optional)