Gorlitz Kensington Clubs Social Adult Day Program for Early-Stage Memory Loss Form for Applicant
Care Partner Name
First Name
Last Name
Name of Club Applicant
First Name
Last Name
Club Applicant Email
example@example.com
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
Emergency Contact other than Care Partner
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone
-
Area Code
Phone Number
Submit
Should be Empty: