Kensington Club@Home Application Care Partner
Name of your Club Applicant
Care Partner Name
Street Address Line 2
State / Province
Postal / Zip Code
Best Phone Number to Reach You
Cell Phone Number if Different
Do you have a diagnosis?
If Yes, what year?
What do you hope to gain from Kensington Club@Home?
Enrichment/Stimulation/Socialization for loved one living with Alzheimer's disease-related dementias (ADRD)?
Respite/Peace of mind for you, the care partner?
How did you hear about JCA Kensington Clubs?
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