Assistance Application - Touched By ALS

Personal Information

Your Name*

Address*

Time at address*

How long have you lived at this current address? (Years/Months)

Date of Birth*

Gender*

Female

Male

Race/Ethnicity*

White

Black

Hispanic

Other

Marital Status*

Married

Separated

Unmarried (single, divorced, widowed)

Email*

Your Phone*

Employment and Income

Employer or major source of income*

Annual Applicant Income*

Annual Applicant Household Income*

NOTE: This information is for research purposes only and does not affect whether applicant receives aid or not.

Health and Assistance

Health Coverage*

How did you hear about Touched By ALS?*

Primary Diagnosis*

Familial ALS

Sporadic ALS

Date of Diagnosis*

Clincial Onset*

Spinal

Bulbar

Date of Onset*

Description of the Assistance Needed*

Projected cost of the Need*

Quote/Invoice

Documentation further explaining the need.

Max. file size: 32 MB.

Have you applied or received assistance before?*

Yes

Assistance provided by

Additional Comments

Pay it Forward*

Would you be willing to share your story and/or a testimonial? This could include photos, video, and a story on our website to help us further advance our mission.

Yes

Phone

This field is for validation purposes and should be left unchanged.