Registering with ALS Quebec will allow you to benefit from all of our programs and services.

You will not only be better equipped to deal with the disease, but you will also have access to important information on ALS.

By registering, you will also be helping ALS Quebec to better understand individuals’ needs within our community. When someone diagnosed with ALS registers, it helps us understand how the disease impacts the lives of Quebecers and Canadians touched by ALS.

If you would rather submit your registration form by mail or fax, download the form here.

Identification


Gender (*)
ManWoman

Preferred language (*)
FrançaisEnglish
Type
BulbarSpinalnot sure
Private medical insurance
YesNo

I would like to receive:

Doctor who diagnosed ALS



Treating Neurologist



Family doctor



CLSC







Readaptation Centre







Other Health Institution







Principal Caregiver








Secondary caregiver








Children of the afflicted person

1st child



2nd child/div>


3rd child



4th child



If form is filled by other than afflicted person

Is the afflicted person aware of this registration?
YesNo




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