Online Support Group Application Form
Date of Birth
Are you currently caring for a family member with dementia?
The person I am caring for is
my spouse / partner
My relative with dementia lives
with another relative
in a nursing home
in another care facility
How did you hear about the Online Support Group?
via The Alzheimer Society of Ireland website
from a member of staff at The Alzheimer Society of Ireland
from a friend / colleague
via the internet
Do you have any special requirements to allow you participate in the Online Support Group (e.g. sight or hearing loss)?
We will be in contact with you about this course. From time to time, we may wish to contact you in relation to other related courses or events of interest to family carers of people with Dementia that ASI are running. We will never share your personal details with any third party. Please tick the box if you agree to being contacted for these reasons
I agree to being contacted by email
I agree to being contacted by post
I agree to being contacted by phone
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Alzheimer Society of Ireland.