Alzheimer Society of Canada Advisory Group Online Application | Candidature en ligne pour le groupe consultatif de la Société Alzheimer

1

I am:* This field is required.

a person living with a form of dementia

a caregiver

neither

2

What is your first name?* This field is required.

3

What is your last name?* This field is required.

4

What province or territory do you live in?* This field is required.

5

Are you comfortable speaking and reading English?* This field is required.Please note that while we welcome bilingual English/French applicants, all of our work will be conducted in English only.

YESNO

6

Do you have access to a computer and can send/receive email, and participate in web conference calls?* This field is required.

YESNO

7

Please select the areas you wish to be involved in:* This field is required.Tick all that apply.

Advising on our strategic direction

Help review educational materials to ensure relevancy to your lived experience

Support our Research Program to review, and learn about, dementia research

Be a spokesperson for various initiatives to erase stigma

Advocate for the Alzheimer Society and dementia needs at the federal level

I just want to be kept informed

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Please enter your email address.* This field is required.We will contact you at this email.

example@example.com

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Please enter your phone number.* This field is required.We may contact you at this phone number if we are unable to reach you by email.

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Phone Number