Early-Stage Memory Loss Social Day Program Application for Member
Kensington Clubs - Kesher Cafe
Name of Applicant
First Name
Middle Name
Last Name
Care Partner Name
First Name
Last Name
Applicant Email
example@example.com
Applicant Birth Date
-
Month
-
Day
Year
Date
Which Club Location?
Parklawn Rockville AM
Parklawn Rockville PM
Germantown (no fee)
White Oak (Silver Spring)
Kesher Cafe Wednesdays (fee)
Kesher Cafe Sundays (no fee)
Applicant Address (if different from Care Partner)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number for Applicant
-
Area Code
Phone Number
Best Cell Phone Number if Different
-
Area Code
Phone Number
Do you have a diagnosis?
Yes
No
If yes, what year?
Other
What do you hope to gain from Kensington Clubs?
I want to do something fun and learn new things.
I want to meet others who are facing the same challenges and make new friendships.
I want to be proactive about my diagnosis and do something about it.
Other
Name of Local Emergency Contact
First Name
Last Name
Address of Local Emergency Contact
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone
-
Area Code
Phone Number
Submit
Should be Empty: