Request Assistance

Currently, we are able to offer 2 distinct types of assistance.

We provide grants of unrestricted financial assistance to those aflicted with ALS and their families.

OR

We can help you with an Event Partnership for your own fundraising efforts. If you are interested in this option, we still need all of the fields completed, and we will contact you to discuss the process in more depth.

Referrals may come from a member of the ALS patient’s medical team (healthcare professionals, social workers, case managers, nurses, therapists, etc.), a family member or friend, or the patient.
The potential recipient must be presently followed by a healthcare provider who is informed about his or her condition.
After completing this form, email the diagnosis letter to info@projectmainst.org
Project Main St. staff will be in touch with the contact person to collect any missing information. All information requested is strictly confidential and required for us to process the application and assure our donors and other constituents that due diligence is taken before assistance is granted.

ALS Patient Info

First Name *

Last Name *

Email *

Date of Birth *

Address Line 1 *

Address Line 2

Phone *

City *

State *

Zip *

Caregiver Info

Does the person needing assistance have a caregiver? * The field Does the person needing assistance have a caregiver? is required.

Caregiver's First Name The maximum length for the field Caregiver's First Name is 500 characters.

Caregiver's Last Name The maximum length for the field Caregiver's Last Name is 500 characters.

Relationship to person needing assistance? The maximum length for the field Relationship to person needing assistance? is 500 characters.

Caregiver's Phone The field Caregiver's Phone must be a phone number.

Caregiver's Email The field Caregiver's Email must be an email.

Clinician/Therapist Info

Diagnosis Date * The date field Diagnosis Date is required.

Prefix * The field Prefix is required.

C/T First Name * The field C/T First Name is required.

C/T Last Name * The field C/T Last Name is required.

C/T Email * The field C/T Email is required.

C/T Phone * The field C/T Phone is required.

General Info

Shipping Address (no PO box) * The field Shipping Address (no PO box) is required.

Service Type Requested * The field Service Type Requested is required.

Describe what we can help you with. * The field Describe what we can help you with. is required.