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, please download the form here.


Gender (*)

Preferred language (*)
BulbarSpinalnot sure
Private medical insurance

I would like to receive:

Doctor who diagnosed ALS

Treating Neurologist

Family doctor


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?