Fred Bargetzi Caregiver Grant

Application Process

The application form requires the following information:

#### ALS Patient Information
1. Name of person with ALS (pALS) - First and Last name (required)
2. Address of pALS - Street address, city, state, ZIP code (required)
3. Best Contact Number (required)
4. Best Contact Email (required)
5. Date of ALS Diagnosis - MM/DD/YYYY format (required)
6. Physician's Name (required)
7. Physician's Phone (required)

#### Applicant Status
8. Please Choose One (required):
- I am a person with ALS (pALS) applying for myself
- I am a caregiver applying on behalf of a pALS

#### Caregiver Information (if applicable)
9. Caregiver Name - First and Last name (required if caregiver is applying)
10. Caregiver Best Contact Number (required if caregiver is applying)
11. Caregiver Best Email (required if caregiver is applying)

#### Additional Information
12. How did you learn about the grant? - Select from:
- Referred by fellow patient, family, or friend
- Found your website myself
- Through another ALS Website

#### Consent
13. Consent checkbox - By clicking, applicant agrees everything on the form is correct and authorizes contact via email (required)
14. CAPTCHA verification (required)

Important Notes

• The program is only available to persons with a confirmed ALS diagnosis
• Physician information is requested only for verification purposes if needed