Family Carer Training Application Form
Name *
Your answer
Address *
Your answer
Phone *
Your answer
Mobile
Your answer
Email
Your answer
Do you have a family member who has Alzheimer's/Dementia? *
Relationship
The person with dementia is my:
e.g. mother, father, husband, wife, partner, etc
Your answer
The age of the person with dementia is:
Your answer
Approximate date my relative was diagnosed
Your answer
My relative lives
Have you used any services of The Alzheimer Society before? *
Course
Desired Location for course *
I would be willing to attend the online course *
How did you hear about insights into dementia? *
If 'Other', please specify
Your answer
Do you have any special requirements for your attendance at the training course e.g. access,communication, print size etc. *
If you have special requirements, please give details
Your answer
Contact
From time to time, we may wish to contact you in relation to events, media or research of interest to family carers of people with Dementia. Please tick the box if you agree to being contacted for these reasons. We will never divulge your personal details to any third party.
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