12/16 LGBTQ Dementia Care Training: Tier 2
Registration Form

Training topics include:

Explain the communication changes that take place throughout the course of the disease.
Decode the verbal and behavioral messages delivered by LGBTQ individuals with dementia and respond in ways that are helpful to them.
Identify strategies to connect and communicate at each stage of the disease.

Date: Wednesday, December 16, 2020

Time: 11:00am – 12:00pm

Location: Zoom

Cost: Free

Please complete the sign-in form. All information is kept confidential and is collected to ensure continued funding from county and state agencies. We are required to ASK all questions, but all are voluntary.

Question Title

1. First name (Required.)

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2. Last name (Required.)

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3. Mailing address (Required.)

Address

City

Zip Code *

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4. Phone number (Required.)

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5. Email (Required.)

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6. Birth date

Month / Day / Year

Date

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7. Race/Ethnicity

White/Caucasian

Black/African American

Hispanic/Latino

American Indian or Alaska Native

Other race

Multiple race

Asian - Indian

Asian - Cambodian

Asian - Chinese

Asian - Filipino

Asian - Japanese

Asian - Korean

Asian - Laotian

Asian - Vietnamese

Asian - Other

Hawaiian/Other Pacific Islander

Declined to state

For Hispanic/Latino or Hawaiian/Other Pacific Islander, please specify:

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8. I am?

Person with Alzheimer's disease or a related disorder

Care partner (family/friend)

Professional

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9. Rural?

Yes

Declined to state

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10. Federal poverty level (FPL)

At or below FPL ($1,041 or less per month for 1 person; $1,410 or less per month for 2 people)

Above FPL

Declined to state

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11. What is your gender

Male

Female

Transgender female to male

Transgender male to female

Genderqueer/gender non-binary

Declined/not stated

Not listed, please specify:

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12. What was your sex at birth?

Male

Female

Declined/not stated

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13. How do you describe your sexual orientation or sexual identity?

Straight/heterosexual

Bisexual

Gay/lesbian/same-gender loving

Questioning/unsure

Declined/not stated

Not listed, please specify:

Thank you for your registration. You will receive the Zoom meeting info by email the day before the event.
If you have any questions, please contact Arthur Chan, LGBTQ Project Manager, Alzheimer's Association at archan@alz.org.

12/16 LGBTQ Dementia Care Training: Tier 2Registration Form

Question Title

* 1. First name (Required.)

Question Title

* 2. Last name (Required.)

Question Title

* 3. Mailing address (Required.)

Question Title

* 4. Phone number (Required.)

Question Title

* 5. Email (Required.)

Question Title

* 6. Birth date

Question Title

* 7. Race/Ethnicity

Question Title

* 8. I am?

Question Title

* 9. Rural?

Question Title

* 10. Federal poverty level (FPL)

Question Title

* 11. What is your gender

Question Title

* 12. What was your sex at birth?

Question Title

* 13. How do you describe your sexual orientation or sexual identity?

12/16 LGBTQ Dementia Care Training: Tier 2
Registration Form

1. First name (Required.)

2. Last name (Required.)

3. Mailing address (Required.)

4. Phone number (Required.)

5. Email (Required.)

6. Birth date

7. Race/Ethnicity

8. I am?

9. Rural?

10. Federal poverty level (FPL)

11. What is your gender

12. What was your sex at birth?

13. How do you describe your sexual orientation or sexual identity?