Alzheimer's Association Community Forum at the City of Wichita Falls MLK Center

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Date: Saturday, March 25, 2023 | 1 - 3 p.m.
Event Address: Martin Luther King Center, 1100 Smith Street, Wichita Falls, TX, 76301
For questions or more information, contact Alyssa Johnston, Program Coordinator, at 940-222-5820 or akjohnston@alz.org

The following questions help the Alzheimer's Association meet the needs of the community. All responses are kept confidential and received directly by the Wichita Falls Regional Office of the Alzheimer's Association. For more information about our Security and Privacy Policy, visit: alz.org/security-and-privacy-policy

Email *

First and Last Name: *

In what year were you born? *

Ex: 1954

Home or Work Address: *

Please include zip code.

Phone Number:

Education:

Please indicate your highest level of formal education.

Organization/Occupation:

Please indicate if retired or unemployed.

You race/ethnicity:

American Indian/Alaska Native

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/Other Pacific Islander

White/Caucasian

Other race/ethnicity

Two or more races/ethnicities

Ask/Declined

Gender:

Do you identify yourself as:

Where did you hear about this program?

Alzheimer's Association Website (alz.org)

Social Media

Newspaper

Advertisement or flyer at a physical location (i.e. a place of business)

Postal Mail

Referral (by physician or health care provider)

Other:

If you were referred to this program, who referred you?

I would like more information about:

Getting a diagnosis

Early stage support

Donating to the cause

Joining a research study or clinical trial

Scheduling a Care Consultation

Other:

Volunteer Interests:

Advocacy Volunteer

Community Education

Community Representative (health fairs, community events, etc.)

Event Volunteer (Walk to End Alzheimer's or The Longest Day)

Faith Outreach Representative

Support Group Facilitator

Other:

A copy of your responses will be emailed to the address you provided.

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