If you are an ALS Caregiver and your income as been significantly reduce because you are caring for your spouse or partner and do not qualify for Government subsidies. You are encouraged to join our ALS Caregiver Registry to take part in direct funding opportunities through donations.

Registration is for 1 year duration, you must register every year to stay on the list.

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Name *

First

Last

Email *

How long have you been helping somebody living with ALS?

Do you live with a person with ALS spouse or partner?

• Yes
• No

If no, do you work for an agency? Which agency?

Does the person with ALS have a source of income?

• Yes
• No

What is their income from insurance, disability, pension, self employment or Government subsidized sources?

Are you a full-time or part-time caregiver?

• Fulltime
• Parttime

Are you employed anywhere full-time or part-time?

• Yes
• No

Do you work self-employed or from home?

• Yes
• No

If yes, what is your monthly or yearly income?

Are you a retired senior?

• Yes
• No

Do you collect any income from insurance, disability, pension or Government subsidized sources?

• Yes
• No

If yes, what is your monthly or yearly income?

Do you receive PSW help?

• Yes
• No

Do you have young children under 16 living at home?

• Yes
• No

Did you have to stop your career to become a caregiver?

• Yes
• No

Is the person you care for a register with the ALS Society?

• Yes
• No

Do you rent or own your home?

• Rent
• Own

Do you need ongoing assistance? or occasion?

• Ongoing
• Occasion

How would you like your name to be published on the registry page?

• First Name Only
• Last Name Only
• First and Last Name
• Anonymous - City

City you live in?

Submit