Language
English (Canada)
French (Canada)
Join The Alzheimer Society of Canada's
Advisory Group of People with Lived Experience of Dementia
I am:
*
a person living with a medically diagnosed form of dementia or cognitive impairment
a care or support partner
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If you are comfortable telling us, what is your dementia diagnosis or the diagnosis of the person you support? (This question is optional)
Alzheimer's Disease
Frontotemporal
LATE NC
Lewy Body
Mild Cognitive Impairment
Vascular
Young Onset
Mixed
I don't know
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What is your full name (first & last)?
*
Please enter your email address.
*
example@example.com
Please enter your phone number.
*
Format: (000) 000-0000.
Which province or territory do you live in?
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
What is your gender?
*
Female
Male
Non-Binary
Other
Prefer Not To Say
If you are willing to share, what is your racial/ethnic background?
*
African
Black
Caribbean
East Asian
Filipino
First Nations
Indigenous Peoples
Latin
Metis
Middle Eastern
Pacific Islander
South Asian
Southeast Asian
White
Prefer Not To Say
I don't know
Are you comfortable speaking and reading English?
*
Yes
No
Do you have access to a computer and can send/receive email, and participate in web conference calls?
*
Yes
No
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