REGISTRATION FORM FOR CAREGIVERS All questions are optional
Person afflicted with ALS
______M / F Name/Surname Region gender
Caregiver Identification
______M / F Name Surname gender
______Address Postal code
______Tel. (home) Tel. (cell) Tel. (work)
______E-mail Date of birth (day/month/year)
Principal Caregiver Secondary Caregiver
Do you wish to receive our e-mail publications? yes no
Do you wish to participate to our conferences and support groups? yes no
Do you wish to participate to our program of friendly visits? yes no
Do you wish to participate to our family pairing program? yes no
Other caregiver(s)
______Name Surname Relationship with afflicted person Date of birth day / month / year Principal Caregiver Secondary Caregiver
______Name Surname Relationship with afflicted person Date of birth day / month / year Principal Caregiver Secondary Caregiver
______Name Surname Relationship with afflicted person Date of birth day / month / year Principal Caregiver Secondary Caregiver
Registration completed
______Date (day / month / year) By (Signature)
I was referred to the ALS Society by: ______
REGISTRATION FORM FOR CAREGIVERS INFORMATION FOR APPUI
NAME CARE-RECEIVER: (Name)______( Surname)______(Gender)_____ M / F
NAME CARE-GIVER : (Name)______( Surname)______(Gender)_____ M / F
CSSS* :______(*if the person knows only its CLSC, see list below)
AGE CATEGORY : Less than 35 years old:____ 55 to 64 years: ____ 35 to 44 years: ____ 65 years and over: ____ 45 to 54 years: ____
WORK : Full time: ____ Part time:____ Unemployed: ____
LANGUAGE: French: ____ English:____ Italian: ____ Spanish: ____ Arabic: ____ Greek: ____ Other (specify):______
HOURS OF WORK DEDICATED TO THE AFFLICTED PERSON WEEKLY: 1 to 4 hours: ____ 5 to 9 hours:____ 10 to 19 hours: ____ 20 hours and +:____
RELATIONSHIP TO THE AFFLICTED PERSON: (who is the caregiver?) Spouse: ____ Child:____ Grandchild:____ Sister/Brother: ____ Friend: ____ Other (specify): ______
CSSS Sud-Ouest/Verdun : CLSC Verdun, Saint-Henri, Ville-Émard-Côte-Saint-Paul CSSS de la Montagne : CLSC de Côte des Neiges, Parc-Extension, Métro CSSS Cavendish : CLSC de Benny Farm, René-Cassin CSSS Bordeaux/Cartierville/Saint-Laurent : CLSC Bordeaux-Cartierville, Saint-Laurent CSSS Ahuntsic/Montréal-Nord : CLSC d’Ahuntsic, Montréal-Nord CSSS Ouest de l’Ile : CLSS de Pierrefonds, Lac Saint-Louis CSSS Pointe de l’Ile : CLSC de Mercier-Est-Anjou, Pointe-aux-Trembles-Montréal Est, Rivière-des-Prairies CSSS Lucille Teasedale : CLSC Hochelaga-Maisonneuve, Olivier-Guimond, Rosemont CSSS Saint-Léonard/Saint-Michel : CLSC Saint-Léonard, Saint-Michel CSSS Jeanne-Mance : CLSC des Faubourgs, du Plateau Mont-Royal, Saint-Louis du Parc CSSS du Cœur de l’Ile : CLSC de la Petite-Patrie, Villeray CSSS Dorval/Lachine/Lasalle : CLSC Dorval-Lachine, LaSalle