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One Family One Cause
MNEAPALS
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Name
*
First
Last
Caregiver Name
*
First
Last
if you are applying for yourself, please put N/A in the boxes above
Relationship to Person Diagnosed with ALS
Phone
Email
*
Preferred Contact Method
Phone
Email
Is this a New Diagnosis (within the last 6 months)
Yes
No
Are you a Minnesota Resident
yes
no
Mailing Address
Street
City, State, Zip
What Type of Emergency Support Do You Need? (Choose All That Apply)
Emergency Support for ALS related Care (I.e hotel, gas, food.)
Immediate Home Safety Need (I.e fall risk, ramp for home access, other home modifications.)
Utility Support Affecting ALS Care (I.e. Electricity, Gas, Water.)
Describe your Emergency Support Needs in your own words (1-3 sentances)
How Would Receiving Support from One Family One Cause Affect your Current Situation (1-3 sentances)
Please Describe your/your loved ones medical situation. Include informationabout treatment of ALS, Progression, and other relevant considerations
If possible, please include medical provider and ALS care coordinator information
Amount Requested
$250
$500
Other
Have you tried other options? (insurance, other charitable organizations, etc.)
Yes
No
Vendor or Payee Name (who we should disperse to)
Vendor Phone
Have you been connected with National Organizations
No
I AM ALS
Team Gleason
ALS Association
ALS United
ALS Network
Project Main Street
CCALS
HARK ALS
attest provided situation.
Would you like support in Navigating services provided by other organizations
yes
no
I understand that I am voluntarily providing this information to One Family One Cause
Yes
No
By submitting this form, I attest under penalty of perjury that all information provided is true and accurate
*
Please enter your full name. (if different then applicants, use your name.)
Submit