Client Registration Form – ALS Society of Canada

Client Information

Name:*

Prefix First Middle Surname

Date of Birth:*

Gender:*

Male
Female
Not Identified

Relationship Status:*

Address:*

Street Address Address Line 2 City Province Postal Code

Is the above address:*

Home
Hospital
Long-term Care
Other

Do you live alone?*

Yes
No

Email:*

Home Phone:*

Cell Phone:

Preferred Language:*

English
French

Preferred method of communication:*

Email
Home Phone
Cell Phone
Text

Choose all that apply

Secondary Contact

Please indicate if your Secondary contact is the preferred contact:*

Yes
No

Name:*

First Last

Relationship to Client:*

Address:*

Street Address Address Line 2 City Province Postal Code

Email:

Cell Phone:

Work Phone:

Additional Contacts

Additional Contact #1:

First name Last name

Phone:

Email:

Additional Contact #2:

First name Last name

Phone:

Email:

Additional Information

Do you have children 21 or under?*

Yes
No

If yes, what year(s) were they born?*

Have you served in the Military or are you a Veteran?*

Yes
No

Additional Information:

Medical Information

Neurologist:*

Address:*

Street Address Address Line 2 City Province Postal Code

Phone:*

Fax:

What is your diagnosis?*

Date of your diagnosis:*

Have you been to any ALS Clinic?*

Yes
No

If yes, which one?*

Insurance Coverage

Do you or your spouse have Extended Health Benefits?*

Yes
No

Name of Health Benefits provider:*

Employment History Information

Client Status of Employment:*

Client Occupation:

Privacy Statement

The ALS Society of Canada respects your privacy. We protect your personal information and adhere to all legislative requirements with respect to protecting your privacy. We do not rent, sell or trade our mailing lists. The information you provide will be used to deliver services and to keep you informed and up to date on the activities of the ALS Society of Canada, including newsletters, program and services. Please notify us of any changes by phone at 1-800-267-4257 or via email at info@als.ca, and we will gladly accommodate your request. I certify that the information contained in this form is true, correct and complete to the best of my knowledge and that I have read and understood the implications of the privacy statement given above. I authorize the ALS Society of Canada to carry out necessary inquiries and obtain or release personal information for the purpose of confirming or clarifying the information provided and for service delivery purposes.

Form Completed By:

Name*

First Last

Phone*

Email*

CAPTCHA