Care for Life

All applications must be received by April 15, 2010.

Ride For Life, Inc. will select a limited number of applications through a random drawing to be held on May 1, 2010.

I am aware that “Care for Life” funding was raised by patients, families, friends and supporters. The program is designed for us to help each other. I have read and I understand the provisions of " Care for Life" and agree to hold Ride For Life harmless from any liability. By submitting this form, I also understand that if it should be found that I had insurance entitling me to a similar type of care received under the auspices of " Care For Life", I shall be responsible for the repayment of such sums to Ride for Life, Inc., and as such, forfeit all past and future benefits derived from this program.

An ALS patient or CAREGIVER may apply. Only one application per patient will be considered. Additional applications will not be considered.

Please answer all questions COMPLETELY.

* Patient's First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

Alternate Phone

* Email Address

* I give permission to Receive Bulk mail? (We need permission to be able to send you email regarding this grant. YOU MUST check the box or this application will be voided.)

Yes, you may contact me via email.

* Date of Diagnosis:

Physician's Name:

Check all that apply:

* The applicant is:

An ALS patient

A caregiver

If you are applying as a caregiver, please tell us about yourself:

* First Name