Dementia Workshop - Registration

Please put your first name in the box below:

Please put your last name in the box below:

Please tell us if you or your loved one is cared for by on of our YoloCares programs OR if you've come to us from the larger COMMUNITY:

Phone

Please enter your email address in the box below:

Are you now or have you ever been someone who provides any kind of care for a sick or dying loved one?

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In the box below, please tell us your approximate age:

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What is the name of the person(s) you care for?

Please put the city where you live in the box below:

What is the name of the county where you live?

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What is your zip code?

The following optional questions help gather data to support securing future funding for our underserved communities.

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Please select from the drop down menu the ethnic group you must closely identify with. If the drop-down choices are not sufficient, please feel free to enter your choice manually.

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Our grant funders seek high levels of inclusivity not only with respect to race and ethnicity, but also gender and sexual identification. With respect for the many and diverse ways people express their identity sexually, we are asking only if you identify as heterosexual or not.

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