ALS Quebec RegistrationHome ALS Quebec Registration Registration Form "*" indicates required fields Registration Form Registering with ALS Quebec provides you with full access to the range of programs and services we offer to people living with ALS or PLS, anyone in their support system, and healthcare providers. Completing this form will take you approximately 5 minutes. After submitting the completed form, you will hear directly from one of our team members within a few business days. If you haven’t heard from us within a week, please contact us directly by email: info@sla-quebec.caGeneral InformationDate of registration DD slash MM slash YYYY I am completing this registration:* On behalf of a person living with ALS or PLS For myself About youI am: A family member or friend of someone diagnosed with ALS or PLS A healthcare provider My First and Last Name(s):* First Last Please let us know how to reach you in case we have questions about the information you have submitted.Preferred telephone number:*Extension The preferred telephone number provided is my:*Please choose oneCell phoneHome phoneWork phoneOtherPlease specify* Preferred email address:* Untitled I don’t have an email/I don’t use the one I have Your statusI am:* Living with ALS or PLS A family member/friend of someone diagnosed with ALS or PLS A healthcare provider Information about the person living with ALS or PLS.First and Last Name(s):* First Last Pronouns:Please choose oneHe/HimShe/HerThey/ThemI prefer to specify myselfPlease specify pronoun Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Preferred telephone number:*Extension The preferred telephone number provided is my:*Please choose oneCell phoneHome phoneWork phoneOtherPlease specify* Other telephone number we can reach you at:Extension This telephone number provided is my:Please choose oneCell phoneHome phoneWork phoneOtherPlease specify Do we have your permission to leave a message?* Yes No Email Untitled I don’t have an email/I don’t use the one I have I prefer the ALS Quebec contacts me by:* Preferred telephone number Text message to my cell phone (please make sure you have provided your cell number above) Email Other Please specify* The best time to reach me is:*Please choose oneMorningAfternoonEveningPlease provide any additional information about the best time to reach you:Preferred language of correspondence:*Please choose oneEnglishFrenchEitherAre there any accommodations we should make to communicate with you effectively?I live:Please choose oneBy myselfWith one or more roommatesWith familyOtherPlease specify Date of birth:* DD slash MM slash YYYY Month of diagnosis:Please choose oneJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear of diagnosis:* Month of first symptoms:Please choose oneJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear of first symptoms: Type of diagnosis:*Please choose oneSpinal/limb onset ALSBulbar ALSPrimary lateral sclerosis (PLS)UnsureTreating neurologist – First and Last Name* First Last Treating Neurologist’s Medical Centre or Clinic Name* Is a file open with the CLSC/CISSS/CIUSSS?*Please choose oneYesNoI'm on a wait listUnsureHow did you hear about us? Check all that apply.* ALS Clinic – CHUM ALS Clinic – Jonquière ALS Clinic – Maisonneuve-Rosemont ALS Clinic – MNI ALS Clinic – Québec ALS Clinic – Sherbrooke ALS Clinic – Other Another person living with ALS CHSLD CLSC Family member or friend Hospital Media Rehabilitation Center Private Practice Website Other Website (please specify):* Other (please specify):* Next* Next*Information about the family member/friend of the person living with ALS or PLS.First and Last Name(s)* First Last PronounsPlease choose oneHe/HimShe/HerThey/ThemI prefer to specify myselfPlease specify pronoun Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Preferred telephone number:*Extension The preferred telephone number provided is my:*Please choose oneCell phoneHome phoneWork phoneOtherPlease specify: Other telephone number we can reach you at:Extension This other telephone number provided is my:Please choose oneCell phoneHome phoneWork phoneOtherPlease specify: Do we have your permission to leave a message?* Yes No Email Untitled I don’t have an email/I don’t use the one I have I prefer that ALS Quebec contacts me by:* Preferred telephone number Text message to my cell phone (please make sure you have provided your cell number above) Email Other Please specify* The best time to reach me is:*Please choose oneMorningAfternoonEveningPlease provide any additional information about the best time to reach youPreferred language of correspondence:*Please choose oneEnglishFrenchEitherAre there any accommodations we should make to communicate with you effectively?I work:Please choose onePart-timeFull timeRetiredI do not workBirth Date* MM slash DD slash YYYY Information about your family member/friend who has been diagnosed – First and Last Name First Last PronounsPlease choose oneHe/HimShe/HerThey/ThemI prefer to specify myselfPlease specify pronoun Relationship with the diagnosed person* Do you live at the same address as the person diagnosed with ALS? Yes No Next* Next*Information about healthcare providers who are registering with ALS Quebec.First and Last Name(s)* First Last Pronouns*Please choose oneHe/HimShe/herThey/ThemI prefer to specify myselfSpecify pronoun* Job title Institution* Institution's postal code* Work telephone number*Extension Work email* Preferred language of correspondence*Please choose oneEnglishFrenchEitherIn what clinical environment do you provide care to people with ALS and/or PLS?*Please choose oneNeurological clinicCLSCRehabilitation centerLong-term care facilityOtherPlease specify clinical environment* Please indicate how you would like to connect with us. Select all that apply.Consent webinar I wish to receive invitations to the ALS Québec’s educational webinars.Consent I wish to be informed about the ALS Québec’s programs offered to healthcare professionals to support them in their work with people living with ALS (exchange forum, community of practice, etc …).Consent I would be interested in offering educational webinars/workshops for ALS Québec.Next* Next*Privacy StatementBy submitting this form, I agree that ALS Quebec can contact me and send regular e-mails providing information about programs, services and other initiatives. Our communications will be explained during the first phone call. If you decide you don’t want to receive emails from us anymore, unsubscribing is easy – just click the link at the bottom of each email and follow the instructions provided. We respect your privacy and are committed to protecting your personal information and adhering to legislative requirements regarding privacy. We do not rent, sell or trade our mailing lists.Consent* If registering on behalf of someone else, I confirm that they have consented to my completion of this registration and to being contacted by ALS Quebec.*Consent* I have read and understand the privacy statement.*