Dementia Workshop - Registration

First Name*

Please put your first name in the box below:

Last Name*

Please put your last name in the box below:

Agency/Community*

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:

Telephone Number*

Phone

Email*

Please enter your email address in the box below:

Would you like to be notified of future events at the Center for Caregiver Support?

Caregiver?*

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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Caregiver Age

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

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Care Recipient

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

City

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

County

What is the name of the county where you live?

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Zip

What is your zip code?

Disclaimer

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

Gender Identity

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Cultural/Ethnic/Racial Background

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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Sexual Identity

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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