Virtual Respite Request Form
Thank you for your interest in the Dementia Society's Virtual Respite Program. If you would like to be matched with a volunteer for Virtual Respite Visits, please fill out the below form.

A staff member from the Dementia Society will contact you within 1-2 business days to discuss your request in more detail and provide you with more information.
First Name *
Last Name *
Phone Number *
Email Address *
I am looking for support (check all that apply): *
Required
I am looking for support primarily in (check all that apply): *
Required
I am primarily interested in:
I am a current client of the Dementia Society: *
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