1. NOMINATION REGISTRATION FORM

Please complete this short online registration form using the information found on the printed KeepSafe iD Nomination Form that was provided by the doctor, the hospital, a first-responder, a community organization, the local senior center, the Area Agency on Aging, a local nonprofit, a residential care community, a home care agency, or others. If you need assistance, please call 1-800-DEMENTIA, leave a message with our call center, and a volunteer will call you back.

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SAMPLE - Front side (page 1) of the paper Nomination Form.

SAMPLE - Front side (page 1) of the paper Nomination Form.

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SAMPLE - Back side (page 2) of the paper Nomination Form.

SAMPLE - Back side (page 2) of the paper Nomination Form.
To complete items 1 - 6 below, please refer to a completed page 2 of the KeepSafe iD Nomination Form as shown in the sample above.

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* 1. FULL NAME of Person Nominated to Use/Wear/Carry the ID (the "Nominee")

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* 2. Enter 8-DIGIT NUMBER found on the back, bottom right.

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* 3. Enter the FULL NAME of the NOMINATOR.

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* 4. Enter the EMAIL ADDRESS of the NOMINATOR.

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* 5. Enter the ORG/BIZ NAME (if applicable) of the NOMINATOR.

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* 6. Enter the DATE SIGNED by the NOMINATOR.

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* 7. YOUR Full Name (the person completing this online form)

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* 8. YOUR Relationship to Nominee? (family, friend, care provider, self, etc.)

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* 9. YOUR Email

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* 10. YOUR Phone Number

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* 11. Is YOUR Phone Number a MOBILE PHONE?

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* 12. Do you have any questions or comments?

Click on SUBMIT to send this online Nomination Registration Form to us electronically.
Please allow up to 10 business days for us to respond by email, text, and/or phone.
Dementia Society of America, PO Box 600, Doylestown, PA 18901; 1-800-DEMENTIA
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