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Hope the Honey Badger ALS
Who We Are
ALS Facts
Mission & History
Board & Staff
Contact Us
What We Do
Programs & Services
Register for Services
National ALS Registry
How To Help
Donate
Volunteer
Get Connected
News & Events
Event Calendar
Photo Gallery
Join Our Mailing List
Hope the Honey Badger ALS
Donate
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Register for Services
Register for Services
Programs & Services
Register for Services
National ALS Registry
PALS Information (Person Needing Assistance)
First Name
Last Name
Date of Birth
Address
City, State, Zip
County
Phone Number
Type of Phone
Mobile
Landline
Is it okay to text message this number?
Yes
No
Alternate Phone Number
Type of Phone
Mobile
Landline
Is it okay to text message this number?
Yes
No
Email (Required)
Preferred contact method:
Phone
Email
Date of ALS Diagnosis
Date of ALS Diagnosis
Neurologist
Have you attended, or are you attending, an ALS Clinic in your area?
Yes
No
ALS Clinic Information:
Is the person needing assistance a veteran?
Yes
No
What is your annual household income?
What is your annual household income?
-----
Under $30,000
$30,001 - $60,000
$60,001 - $90,000
$90,001 - $120,000
$120,001 or over
Prefer not to answer
Primary Caregiver
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Caregiver First Name
Caregiver Last Name
Relationship to Person needing services
Does the primary caregiver reside with the person needing assistance?
Yes
No
Caregiver Phone Number
Caregiver Phone Type
Mobile
Landline
Is it okay to text message this number?
Yes
No
Caregiver Email
Secondary Caregiver (Optional)
Secondary Caregiver First Name
Secondary Caregiver Last Name
Relationship to person needing assistance
Secondary Caregiver Phone Number
Secondary Caregiver Email
Who would you prefer us to communicate with?
Who is completing this form?
Services
I am most interested in the following program service(s)
Education, Guidance and Community Resources
Individual and Group Support
Respite Grant Program
Equipment Loan Program
Children's Funds
Brad Meyer Memorial Scholarship
Alternative Services
Referrals to Experienced Medical Professionals
Volunteer Assistance
Other
Additional Comments
American National Bank
Bear Properties
Burn Boot Camp Gretna
Continental
Empyrean Brewing Co.
EPCO
Equitable Bank
Hillcrest
McKeans Floor to Ceiling
Mitsubishi Tanabe Pharma America, Inc.
Orthomedics
Piedmontese and Mercato
Platinum Title and Escrow
Spikes Beach Bar and Grill
Team Gleason
Tevra Brands
trb ARCHITECTURE
Vitalize Health, LLC.