Texas Registration Form
Person with ALS
Suffix (Mrs., Mr., Miss., etc.)
First Name
Last Name
Street Address
City
State
Zip Code
Phone
Email
Gender
Please select...
Female
Male
Prefer not to answer
Non binary / third gender
Date of Birth
Are you a Veteran?
Yes
No
Who is filling out this form?
Please select...
Self
Clinic/Medical Provider
Family Member
ALS Texas Staff
Other
Please select the ALS Clinic you attend
Please select...
South Texas VA
Austin Neuromuscular Center
Baylor College of Medicine
Central Texas Neurology Consultants
Central Texas VA ALS Clinic (Austin)
Central Texas VA ALS Clinic (Temple)
Doctors Hospital Renaissance, LTD
Emory Bellard ALS Clinic at Baylor Scott & White
Houston Methodist
Texas Neurology
Texas Tech University Health Sciences Center El Paso
UT Health San Antonio
Houston VA
Other
Neurologist or ALS Clinic
Diagnosis Date (or estimate)
Onset Type:
Employer/Retired From
Who is your primary insurance provider?
Please select...
Medicare Supplement
Medicare Part D
Medicare Part A/B
Medicare Advantage/Part C
Medicaid
Private Insurance
VA Insurance
Tricare
Alaska Native/Indian Health/Tribal Health Services
COBRA
Employer Group Health Plan
Exchange
Off-Exchange
Other
None at this time
Do not Know
List any additional insurance providers here
We offer support for children. youth, and young adults. Do you have any children, grandchildren, etc. ages 5 - 30 years old?
Yes
No
Spouse/Immediate Family/Primary Caregiver
Suffix (Mrs., Mr., Miss., etc.)
First Name
Last Name
Phone
Email
Gender
Please select...
Female
Male
Other
What is your relationship?
Spouse/Partner/Significant Other
Family
Friend
Are you interested in learning more about the Walk to Defeat ALS?
Yes
Not right now
Additional information (optional)
Yes, I would like to receive occasional text messages from the Texas Chapter!
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