Pen Pal Form

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City Province

Postal Code Country

Phone *

Area Code Phone Number

E-mail *

Gender *

Male Female

I am in the following stage of my journey: *

Person living with dementia is in the Early Stages Person living with dementia is in the Middle Stages Person living with dementia is in the Late Stages Person living with dementia resides in Long-Term Care Person living with dementia is deceased

Preferred form of correspondence: *

Email Postal mail

I prefer to correspond with:

Male Female I have no preference

I prefer to correspond with another care partner in the following stage of their journey:

Person living with dementia is in the Early Stages Person living with dementia is in the Middle Stages Person living with dementia is in the Late Stages Person living with dementia resides in Long-Term Care Person living with dementia is deceased I have no preference

PEN FRIENDS Program Waiver

By checking the boxes below I agree and understand that (check all): *

The PEN FRIENDS Program is intended to provide companionship and informal/peer support through post or by email. To discuss issues directly related to caring for someone living with dementia or if you require professional support you can contact the Alzheimer Society of Niagara Region at (905) 687-3914. The Alzheimer Society of Niagara Region will provide my contact information such as name, mailing address or email address to another care partner registered for the PEN FRIENDS program for the purpose of sending and receiving peer support letters and/or emails. I understand that the Alzheimer Society of Niagara Region is not providing direct supervision of the correspondence shared in this program. I agree to indemnify and hold the Alzheimer Society of Niagara Region harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities,including attorney’s fees brought as a result of my involvement in the PEN FRIENDS Program.

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PEN FRIENDS Registration

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