Conference Registration Form

Understanding Dementia: A Caregiver's Perspective

This FREE one-day conference, hosted by Mountain Empire Older Citizens, is dedicated to empowering, educating, and connecting caregivers who support individuals living with dementia. Whether you're a family member, professional caregiver, or non-professional caregiver, this event offers resources, expert-led sessions, and a supportive environment to enhance your caregiving journey.

Why Attend?
- Gain actionable strategies and insights
- Connect with a supportive community
- Access tools and resources for daily caregiving
- Leave feeling informed, empowered, and less alone

The conference will be held on October 14th, 2025, at Heritage Church of God in Big Stone Gap, VA from 10 am - 3 pm. Please make plans to attend the entire day.

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1. Caregiver Name (Required.)

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2. Mailing Address (Required.)

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3. Email

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4. Phone number (Required.)

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5. Do you have dietary restrictions? (if yes, please specify)

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6. Do you require any accessibility accommodations? (if yes, please specify)

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7. Do you require transportation to and/or from the event? (Required.)

Yes

Unsure

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8. How did you hear about the event?

Facebook

Newspaper

MEOC Website

Friend or Family

Other (please specify)

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9. Do you grant permission for MEOC to use event photographs that may contain your image in future publications? (Required.)

Yes

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10. Would you like receive future mailings from MEOC regarding dementia and/or caregiver information? (Required.)

Yes

Conference Registration Form

Understanding Dementia: A Caregiver's Perspective

Question Title

* 1. Caregiver Name (Required.)

Question Title

* 2. Mailing Address (Required.)

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* 3. Email

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* 4. Phone number (Required.)

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* 5. Do you have dietary restrictions? (if yes, please specify)

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* 6. Do you require any accessibility accommodations? (if yes, please specify)

Question Title

* 7. Do you require transportation to and/or from the event? (Required.)

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* 8. How did you hear about the event?

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* 9. Do you grant permission for MEOC to use event photographs that may contain your image in future publications? (Required.)

Question Title

* 10. Would you like receive future mailings from MEOC regarding dementia and/or caregiver information? (Required.)

1. Caregiver Name (Required.)

2. Mailing Address (Required.)

3. Email

4. Phone number (Required.)

5. Do you have dietary restrictions? (if yes, please specify)

6. Do you require any accessibility accommodations? (if yes, please specify)

7. Do you require transportation to and/or from the event? (Required.)

8. How did you hear about the event?

9. Do you grant permission for MEOC to use event photographs that may contain your image in future publications? (Required.)

10. Would you like receive future mailings from MEOC regarding dementia and/or caregiver information? (Required.)