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Taking Care - Viewing Information
*
1.
Name:
(Required.)
*
2.
Email:
(Required.)
*
3.
Why are you interested in this film?
(Required.)
4.
Are you caring for someone with Dementia?
Yes
No
5.
Are you a senior care professional?
Yes
No
6.
If you answered yes to Q5 please answer the following:
Name of Organization/Business:
City and/or Service Area:
Title:
Service(s):
7.
Parks' Place will be having a live screening of the movie at our community on Tuesday, March 4th at 2 pm, would you be interested in attending? (snacks, social time before and after the film, and tours will be available)
Yes
No
Thank you for completing!
Please go to next page for viewing instructions.
