Programs & Services
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1. Default Section
1
. What best describes you:
What best describes you:
I have Alzheimer's disease
Other dementia
I am/was a caregiver to someone with Alzheimer's
I am a professional
2
. Please tell us your county and state
Please tell us your county and state
3
. Have you ever attended an Alzheimer's educational program?
Have you ever attended an Alzheimer's educational program?
Yes
No
4
. If not, can you tell us why?
If not, can you tell us why?
5
. Would you need respite services to come to an educational program?
Would you need respite services to come to an educational program?
Yes
No
6
. What day(s) of the week are best for you to attend a program? Check all that apply:
What day(s) of the week are best for you to attend a program? Check all that apply:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
7
. What time of day is best for you to attend an educational program? Check all that apply:
What time of day is best for you to attend an educational program? Check all that apply:
Early morning (7am-10am)
Mid-morning (10am-Noon)
Early afternoon (Noon-2pm)
Late afternoon (2pm-5pm)
Early evening (5pm-7pm)
Late evening (7pm or later)
8
. What topics would be of assistance or interest to you? Check all that apply:
What topics would be of assistance or interest to you? Check all that apply:
Alzheimer's: Beginning the Conversation
Dementia & Driving
Maintain Your Brain
Activities for People with Alzheimer's
Research Update
Partnering with Your Physician
Alzheimer's & the Holidays
Grief & Mourning
Difficult Symptoms
9
. Are there other topics you would be interested in learning more about?
Are there other topics you would be interested in learning more about?
10
. If you would like more information regarding upcoming Alzheimer's education programs/events in your area, please complete the information below:
If you would like more information regarding upcoming Alzheimer's education programs/events in your area, please complete the information below:
Name:
Street Address:
Apt/PO Box
City
State
Zip
Email Address
Phone Number
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