Extra Hands for ALS

Extra Hands for ALS - Los Angeles/Orange County Chapter - ALS Family Registration

Thanks for your interest in Extra Hands for ALS. This form is for ALS Families. If you are interested in registering as an Extra Hands Student volunteer or as a Mentor, please click here:

Extra Hands Student registration
Extra Hands Mentor registration

We're looking forward to meeting you!

Information About the Person With ALS

First Name *

Last Name *

Email: *

Phone Number *

(xxx) xxx-xxxx

Street Address

City

State

Zip

Primary Caregiver

Primary Caregiver Cellphone Number

(xxx) xxx-xxxx

Identity

Race:

Gender:MaleFemale

Birthdate: *

Insurance

Do you have health insuance?YesNo

If so, does the policy cover respite care?YesNo

Do you have disability insurance?YesNo

If so, does the policy cover respite care?YesNo

Interest in Extra Hands

Which aspect of Extra Hands are you interested in? *Weekly visit from two students for two hours
One-day projects involving many students
Public awareness initiatives and fundraisers

When would you prefer Extra Hands? *Monday 4-6pm or 7-9pm
Tuesday 4-6pm or 7-9pm
Wednesday 4-6pm or 7-9pm
Thursday 4-6pm or 7-9pm
Friday 4-6pm or 7-9pm
Saturday morning or afternoon
Sunday morning or afternoon

Volunteer Activities

Please place a check next to things you would like Extra Hands students to do. Please note that only non-medical assistance is provided through the Extra Hands program.All activities
House cleaning (vacuuming, dusting, bathrooms, windows, dishes, laundry)
Yard work (mowing, raking, gardening, shoveling snow, yard projects)
Run errands (groceries, dry cleaning, etc.)
Home office (typing, editing, filing, mail/email, computer work/setup)
Babysitting
Pet care (dog walking, pet feeding, etc.)
Reading aloud
Preparing meals
Companionship (keep patient company with or without other caregivers present)s class="oneChoice">Assistance with hobbies or projects (photo albums, painting, sewing, arts & crafts, etc.)

Please use the space below to describe any ideas you may have of additional things you would like Extra Hands students to do. Again, please note no medical services are provided through the Extra Hands program.

Extra Hands for ALS adheres to a strict policy prohibiting sexual molestation, abuse, and harassment. Both volunteers and patients have the right to request being matched with someone of a particular gender. All parties must read and agree to Extra Hands for ALS policies before participating. If you have any questions or concerns in this regard, or if you have any other special considerations, please indicate so on this form or contact us at the numbers above.



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