Share Your Story - An ALS Awareness Project

Sharing our experiences with ALS is a critical part of raising awareness about this devastating disease.

Everyone can help, whether you're a person living with ALS, family member, friend, or concerned individual. In doing so, you are making a difference to the ALS community as we work together to raise awareness and funding to fuel the search for effective treatments and cures for ALS.

Please take a moment and fill out the questions below. You may want to draft your comments separately before entering them below. If you have any questions, please contact us!

1. Field Is Required What is your connection to ALS?

I am a person with ALS
I am a family member of a person who has ALS
I am a friend with someone with ALS
I am a coworker or colleague of a person with ALS
I am a healthcare provider for people with ALS
I am affiliated with an organization that serves the ALS community
I am interested in supporting the ALS community
Other/Decline to state

2. Tell us some general information about yourself and/or your loved one. The purpose of this is to show what your life was like before ALS became a part of it. (Examples: Where are you from? Where did you go to school? Where did you meet your significant other? What kind of work do you do? Did you volunteer with other organizations before? )

3. If you are a person with ALS or one of their loved ones, please enter the age and the date of the diagnosis.

4. Tell us more about yourself and/or your loved one. (What were the first symptoms? Where are you receiving your care? How has ALS affected your daily life? When did you start volunteering? etc) :

5. What are some important details about your experiences with ALS that you would want the general public to know about?

6. What are some of the ways that you have been participating with the ALS community and with The ALS Association Golden West Chapter. This could include activities like attendance at support groups, participation in community outreach events, receiving care or participating in a clinical trial at an Association-supported clinic or center, following us on social media, being an ALS advocate, and more.

7. If there was "one thing" that you would like to share about your experiences with ALS and as a part of the ALS community with the general public, what would it be?

8. Field Is Required MEDIA RELEASE: By participating in this project, I hereby give my consent for The ALS Association Golden West Chapter for the following: 1. To use my comments, photos, and story in their public awareness campaigns. 2. To use my likeness in still photographs for media and awareness use which may include newsletters, articles, website posting and other such materials. My recompense for this effort is the satisfaction of helping others learn about ALS, the work of The ALS Association and the Golden West Chapter, and the personal enjoyment of participation in a worthwhile project to raise awareness about the disease. I acknowledge that I own the copyright to the images that I am submitting or that I have obtained the written permission of the copyright owner.

9. Please enter some information about yourself in the fields below: (For proper photo credit and release of information)

Title

Field Is Required First

Field Is Required Last

Suffix

Field Is Required Street 1:

Street 2:

Field Is Required City/Town:

Field Is Required State / Province:

Field Is Required ZIP / Postal Code:

Country:

Field Is Required Email:

Phone Number:

If you respond and have not already registered, you will receive periodic updates and communications from Golden West Chapter.

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Thank you for sharing your ALS story!