ALS Quebec Registration

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.ca

General Information

Date of registration

I am completing this registration:*

On behalf of a person living with ALS or PLS

For myself

About you

I 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 specify*

Preferred email address:*

Untitled

I don’t have an email/I don’t use the one I have

Your status

I 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 specify pronoun

Address*

Street Address Address Line 2 City Province Postal Code

Preferred telephone number:*

Extension

The preferred telephone number provided is my:*

Please specify*

Other telephone number we can reach you at:

Extension

This telephone number provided is my:

Please specify

Do we have your permission to leave a message?*

Yes

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)

Other

Please specify*

The best time to reach me is:*

Please provide any additional information about the best time to reach you:

Preferred language of correspondence:*

Are there any accommodations we should make to communicate with you effectively?

I live:

Please specify

Date of birth:*

Month of diagnosis:

Year of diagnosis:*

Month of first symptoms:

Year of first symptoms:

Type of diagnosis:*

Treating neurologist – First and Last Name*

First Last

Treating Neurologist’s Medical Centre or Clinic Name*

Is a file open with the CLSC/CISSS/CIUSSS?*

How did you hear about us? Check all that apply.*

Website (please specify):*

Other (please specify):*

Information about the family member/friend of the person living with ALS or PLS.

First and Last Name(s)*

First Last

Pronouns

Please specify pronoun

Address*

Street Address Address Line 2 City Province Postal Code

Preferred telephone number:*

Extension

The preferred telephone number provided is my:*

Please specify:

Other telephone number we can reach you at:

Extension

This other telephone number provided is my:

Please specify:

Do we have your permission to leave a message?*

Yes

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)

Other

Please specify*

The best time to reach me is:*

Please provide any additional information about the best time to reach you

Preferred language of correspondence:*

Are there any accommodations we should make to communicate with you effectively?

I work:

Birth Date*

Information about your family member/friend who has been diagnosed – First and Last Name

First Last

Pronouns

Please specify pronoun

Relationship with the diagnosed person*

Do you live at the same address as the person diagnosed with ALS?

Yes

Information about healthcare providers who are registering with ALS Quebec.

First and Last Name(s)*

First Last

Pronouns*

Specify pronoun*

Job title

Institution*

Institution's postal code*

Work telephone number*

Extension

Work email*

Preferred language of correspondence*

In what clinical environment do you provide care to people with ALS and/or PLS?*

Please specify clinical environment*

Please indicate how you would like to connect with us. Select all that apply.

Privacy Statement

By 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.