HFC Online Support Group Interest Form
Thanks for your interest in joining one of HFC's Online Support Groups! This unique opportunity is for caregivers of loved ones living with Alzheimer's disease and related dementias. HFC's groups are led by credentialed social workers and trained group leaders who have experience supporting dementia family caregivers.

HFC support groups are FREE and most groups meet weekly. We will do our best to match you based on your availability and the information you provide below. It can take up to three weeks to fulfill your request so we thank you for your patience.


If you have any questions, don't hesitate to contact us - care@wearehfc.org

Para completar este formulario en español, haga clic aquí.
Sign in to Google to save your progress. Learn more
If you are signing up for one of HFC's affiliate support groups, please indicate your selection below.
Please tell us your name! (First and Last Name) *
And your email address *
And your phone number *
Please provide your home address: *
Which day(s) of the week work best for you to commit to a weekly group session? Check all that apply. *
What time of day works best for you to participate in a group session? Check all that apply. All times are in Eastern Standard Time. *
The person I am caring for or cared for is my: *
Please share your age group so we can best match you to a group. *
Please share your preference for being matched with a group.
HFC offers a range of support for Alzheimer's family caregivers, please indicate if you are interested in any of the services below: *
Anything else you want us to know about you or your caregiving experience?
How did you hear about HFC's Online Support Groups?
Please provide us with emergency contact information to be shared with the support group facilitator once you have been matched with a group.  We ask for an emergency contact in the event that there is any concern for your well-being or if you experience a medical emergency while attending the group.

Please provide a FULL NAME AND PHONE NUMBER below.
By checking here, I give my consent for the practitioner to contact my emergency contact if there is concern about my well-being or I experience a medical emergency.

HFC is not a medical provider, nor will HFC possess or retain your personal healthcare information or that of your loved ones suffering from Alzheimer’s (“PHI”) without your express disclosure and release of PHI.  To the extent you disclose any PHI without obligation of nondisclosure on the part of all participants in a support group, such information may be deemed to be non-confidential.  Notwithstanding the foregoing, we ask that participants adhere to a sense of understanding and sensitivity with respect to others’ personal information disclosed in support groups.

In consideration of HFC allowing me to participate in HFC’s support groups, and/or use HFC’s other services (collectively, “HFC Services”), I agree that if I engage in any activity hosted by HFC or its representatives (including support group facilitators) or accept the benefit of HFC Services, I do so at my own risk. I hereby certify and declare that on behalf of myself and, as applicable, each of my minor children, spouse, heirs, beneficiaries, attorneys, agents and assigns, I hereby waive, will release, covenant not to sue, and forever hold free and discharge from any liability HFC and each of its, affiliates, agents, directors, officers, employees, contractors, instructors, volunteers and representatives (collectively, the “HFC Parties”), of and from all claims, demands, rights and causes of action of any nature whatsoever, which may have or which may hereafter accrue to me,  arising out of or in connection with the conduct, acts, or omissions of the HFC Parties, and my use of HFC Services, whether known or unknown, seen or unforeseen, resulting from my participation in HFC support groups or otherwise accepting HFC Services, including, without limitation, any data breach or loss of privacy.  

Further, knowing and understanding these risks, nevertheless, I hereby agree to voluntarily assume these risks and agree to indemnify the above-named released HFC Parties in the event my family pursues any claim waived and/or released herein. I understand that this indemnification includes payment for all loss, including any court or arbitration costs, attorney’s fees, awards incurred by or adjudged against the above-named released HFC Parties.

FOR SUPPORT GROUP PARTICIPANTS:  By checking here, I acknowledge that I know and have carefully read this waiver and release and fully understand and have had this document explained to me, that it is a release of liability. This waiver and release is intended to be interpreted as broadly and all-encompassing as permissible under applicable law. If any portion of this agreement is found to be void or unenforceable, I agree that the remaining portions shall remain in full force and effect.  *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Hilarity for Charity. Report Abuse