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Request Assistance


You can't do it on your own.  ALS is a terrible disease that takes all your physical abilities away while leaving you with the mental capacity to realize everything that's happening.  Let us know how we can help.  Download the two forms below, fill them out, and then mail them back to us or scan them and upload them using the link below.  We'll do everything we can to assist you with the resources that are available to us.  

Step 1:

Step 2:

Step 3:

Step 4:

Click each application link and download the form to your computer.

Fill out the forms completely, get your physician's signature, and then go to step 3.

Click the button to the right and upload a completed form.  Then go to Step 4.  Repeat steps 3 & 4 for the second form.




Once you have uploaded both forms, click Send.

Alternatively you can mail the completed forms back to us here:

Shred ALS Foundation

6472 Redmont Ct

Liberty Twp, OH 45044

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