I AM ALS Peer Support Initiative: Mentor Application

Thank you for your interest in becoming a Mentor to people affected by ALS! All information shared through this application will be kept confidential, and will not be shared without your explicit consent.

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* 1. Please share your birth date to confirm that you are 18 years of age or older.

Date of Birth

Date

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* 2. Please share your name and contact information below.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. What is your connection to ALS? Select all that apply.

I have been diagnosed with ALS

I am the primary caregiver for a loved one with ALS

I am a loved one of someone diagnosed with ALS

I lost someone diagnosed with ALS

I do not have a connection to ALS

Other (please specify)

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* 4. What is your relationship to the person diagnosed with ALS?

Self

I am their spouse

I am their domestic partner

I am their parent

I am their adult child

I am their friend

I am their paid caregiver

Other (please specify)