Thank you for your interest in the National Center for Equitable Care for Elders' Supporting Family Caregivers of Older Adults with Dementia Learning Collaborative. This learning collaborative will focus on skill-building in supportive care approaches for older adult patients with dementia and their caregivers and will be held on January 25th, February 1st, February 8th, and February 15th from 1:00-2:00 PM ET. 

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* 1. What is your first and last name?

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* 2. What is your email address?

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* 3. If you'll be calling in during each learning collaborative session, what phone number will you be using?

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* 4. What is the name of your organization? (Note: Our training and technical assistance is intended for HRSA-funded health center and health center program look-alike personnel. If you are unsure if your organization is a HRSA-funded health center or look-alike, you can check out HRSA's Find a Health Center resource for clarification.)

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* 5. What is your position? 

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* 6. Supervisor Name 

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* 7. Supervisor Email
(Note: Supervisors will be contacted and asked to acknowledge their support for your participation in this activity.)

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* 8. How did you hear about this learning collaborative?

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* 9. Why did you register for this learning collaborative?

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* 10. What do you plan to do with the information you learn from this learning collaborative?

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* 11. How ready are you to implement the information from this learning collaborative at your health center?

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* 12. What percentage of your health center's patient population are older adults aged 65 and older?

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