Champion Training - Dementia Friends Washington

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Thank you for your interest in becoming a Dementia Friends Champion. Please complete this form to the best of your ability so that we can learn more about you and help customize our training time together.

Email *

Name

Briefly describe your experience providing trainings or in public speaking.

Suggestion to provide number of years of experience, the topic of the trainings, and for what organization, if applicable.

What County are you located?

What experience do you have with persons with dementia? Please check all that apply.

I am a person with dementia.

I provide care for a loved one with dementia.

I provided care for a loved one with dementia in the past.

I work with persons with dementia.

I have family, friends or acquaintances with dementia.

I have no prior connection to persons with dementia

Other:

What year were you born?

What is your employment status?

Student

Full time employment (30 or more hours/week)

Part time employment

Volunteer

Not currently employed

Other:

Clear selection

Which of the following would you use to describe yourself?

White

Hispanic or Latino (a)

Black or African American

Asian or Asian American

Native Hawaiian/Pacific Islander

American Indian, Alaskan Native

Other:

Which of the following best represents your current gender?

Female

Male

Gender queer or non-binary or gender expansive

Other:

Clear selection

What is the highest level of education you have completed?

Less than high school

High school or GED

Less than 4 years of college

4 year college degree

More than 4 years of college (master’s degree or higher)

Clear selection

What kinds of groups or formal/informal networks are you connected with, if any? (i.e. service club, religious institution, sports team, work or volunteer organization, cultural group, neighborhood association, school, book group)

Anything else you want to share about your background or interests?

Submit

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