Life After Stroke

Electronic Signature: Typing your name in the box below and then clicking on the "Submit" button below serves as your agreement to the "Life After Stroke" Terms of Use. *

State: *

I am a: *

Stroke Survivor

Caregiver

A family member or loved one (but not the caregiver) of a Stroke Survivor

We are here to help. Please tell us what you hope to get out of attending this online support group: *

ONLINE SUPPORT GROUP RSVP FORM

Email address: *

"Life After Stroke" Online Support Group

Terms & Conditions:

Each weekly "Life After Stroke" online support group includes a "open" group discussion with people from around the world. Any information you share with others during the support group is up to you and is your determination to share. It is also understood that the organizers of the online support group are first and foremost dedicated to providing helpful information regarding stroke. You also understand and agree that any personal information that you share openly during the support group becomes public information just by virtue of your open public disclosure. Thus, you are advised to only openly share information that you are comfortable becoming public knowledge. We are not responsible for any of your personal information being shared in any way by other participants of the support group.

You also understand and agree that any medical advice or tips given by anyone participating in the support group are their own opinions and not necessarily those of the organizers of the "Life After Stroke" support group. You are hereby advised to never change any of your medications or modify any part of your medical routine without first consulting your doctor or therapist.

Age *

City: *

Daytime/Cell Phone: *

Your Name: *

What "other" way:

How did you hear about the "Life After Stroke" online support group? *

Heard the "Life After Stroke" radio show

Doctor or Therapist recommendation

From another support group I attend

From a fellow stroke survivor/caregiver

Saw a flyer or advertisement

Received an email

Internet search

Other

Thank you for you interest in joining the "Life After Stroke" Online Support Group!

We are very excited to be able to offer this unique support group to stroke survivors and caregivers who don't have access to a stroke support group in their area.

The support group is held every Thursday at 11 am pacific time online on TheStrokeChannel.TV website.

Stroke survivors, their caregivers and their loved ones are welcome!

If you would like to take part in our weekly "Life After Stroke" online support group,

simply fill out the form below and log in information will be sent to you via email!