Dementia Friendly Business/Organization Training Registration
In return for attending the training, this business/organization will:

1) Receive a “Dementia Friendly Business” certificate and window decal for store front

2) Become featured on the Dementia Friendly Iowa social media pages and website (photo of staff and logo)

3) Gain skills to identify and communicate with a customer/client who may have dementia

4) Receive recommendations about how to modify business practices to best serve people living with dementia and their caregivers

5) Have the opportunity for individual staff members to be considered "Dementia Friends"


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Email *
Primary Contact Name/Title *
Business/Organization Name (as it will be listed on the certificate and social media post for recognition) *
Would you prefer to be referred to as a Dementia Friendly "Business" or "Organization"? *
Primary Contact Phone Number *
Mailing Address *
Physical Address (skip if same as mailing address)
Where will the training session be held? (your office, Zoom, other location...) *
Please check the sector that is most applicable *
This business/organization is committing to becoming dementia friendly by doing the following (must check all boxes) *
Required
Total number of staff in your business/organization? *
Total number of attendees you expect to be at the training? (approximate) *
What do you hope to learn from the training? Any specific situations or topics you would like to see covered?
Technology Setup for Training Presentation: Our training does require ability to show a Google Slides presentation with videos (sound required). Please indicate what the setup will be for technology.  *
The standard training takes 1 hour. Please provide us 3-5 date/time options that work well for you and your staff. If you have already scheduled a time with a Champion trainer, please indicate the time/date here. *
(Due to volunteer availability, we are not able to guarantee these times will work, especially evenings and weekends, but we will do our best to find a time to meet your staff schedule.)
How did you hear about this opportunity? Did someone in particular connect with you about becoming a Dementia Friendly Business? Are you already working with a Champion (presenter) locally?  *
Donation (optional)
Thank you for taking the step to become a more dementia friendly business! Our team will be reaching out to you as soon as possible to schedule the training.

Dementia Friendly Iowa is on a mission to educate people to make our state a place where people with dementia can truly thrive. This requires funding for time and materials for the Champion/Organization presenting your training. We would love your support if you are able!

If you plan to donate, you may choose to make a donation to the Supporting Organization offering the session, or you can donate to the greater Dementia Friendly Iowa movement.

To make the contribution to the Dementia Friendly Iowa movement, you may do so online here: https://www.nei3a.org/support-nei3a/donation-form.aspx

You can also donate via check. The check can be written out to the Northeast Iowa Area Agency on Aging, with “Dementia Friendly” in the memo.

Please mail contributions to:
NEI3A
201 Tower Park Dr. Suite 100
Waterloo, IA 50701

We thank you so much for your support!
A copy of your responses will be emailed to the address you provided.
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