Power of Music Registration Form

* Please note that participants must be able to engage independently in the program or be accompanied by a care partner. This is not a respite program and staff are unable to provide personal care support, physical or medical assistance, and are not able to prevent participants from leaving the venue.

Choose the series you would like to attend:*

April 16 - May 21, 2026 (Niagara Falls)

Date: Thursdays from April 16 - May 21, 2026
Time: 1:00 pm - 2:30 pm
Place: Niagara Falls Legion (5603 Spring St., Niagara Falls)

Music enhances all of our lives and is especially beneficial for persons with dementia or memory change. Hearing our favourite song can bring us back to a moment in time and allows us to tap into meaningful memories from our past.

Join us for the Power of Music program where we will reminisce to our favourite songs and participate in music-themed activities. This program is open to persons living with dementia or memory change and care partners as well.

How many people will be attending? (max 2)*

Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Date of birth*

For helping with music selections!

Is the Individual Living With Dementia a returning friend who has registered for an Alzheimer Society of Niagara Region program in the past (including Power of Music)?*

YesNoUnsure

The Alzheimer Society Niagara Region is committed to providing the highest quality of support and services to our community. To help us understand better the population we serve, we are requesting additional demographic information. Gathering this information not only helps us tailor our programs to meet the unique needs of our community, but it also plays a crucial role in our ability to apply for and receive funding through Ontario Health and private grants, which require detailed demographic data to support our initiatives. As a healthcare custodian, we are responsible for collecting, managing, and protecting this information in compliance with all applicable privacy standards. Your participation in providing this data helps ensure that we can continue delivering effective, person-centered care to those impacted by dementia.

If you prefer not to answer a specific question, you may choose that option in the questions drop box.

Language Spoken at Home

Mother Tongue

Gender

Racial or Ethnic Group

Health Card Number

Health Card Version

Birth year

For helping with music selections!

Favourite genre of music or favourite artist/band

This will help us further tailor the music to the group!

Name

Address same as above?

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Is the Care Partner a returning friend who has registered for an Alzheimer Society of Niagara Region program in the past (including Power of Music)?

YesNoUnsure

The Alzheimer Society Niagara Region is committed to providing the highest quality of support and services to our community. To help us understand better the population we serve, we are requesting additional demographic information. Gathering this information not only helps us tailor our programs to meet the unique needs of our community, but it also plays a crucial role in our ability to apply for and receive funding through Ontario Health and private grants, which require detailed demographic data to support our initiatives. As a healthcare custodian, we are responsible for collecting, managing, and protecting this information in compliance with all applicable privacy standards. Your participation in providing this data helps ensure that we can continue delivering effective, person-centered care to those impacted by dementia.

If you prefer not to answer a specific question, you may choose that option in the questions drop box.

Language Spoken at Home

Mother Tongue

Gender

Racial or Ethnic Group

Date of birth

Date

Disclaimer

This information will be used for statistical purposes and will be stored on our electronic database; it will be kept confidential and will not be shared outside of our organization. I freely consent to participate in the offered program that will be led by an Alzheimer Society staff member or volunteer. I acknowledge that it is my choice to participate in this activity and I understand that I am free to withdraw from, reduce or modify my involvement in any part of this activity. I understand the program is not a supervised respite service and I must be able to independently participate. For programs where food is served, I understand that the organization can only serve store bought, pre-packaged foods, and cannot guarantee an allergen-free environment. I understand the Alzheimer Society of Niagara Region has taken reasonable safety precautions, including following Ontario Public Health recommendations, as a response to Covid-19. I agree to indemnify and hold the Alzheimer Society of Niagara Region harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement. In the event that a program session must be cancelled due to unforeseen circumstances, we will attempt to contact you if given permission above. Participants are encouraged to phone the Alzheimer Society of Niagara Region regarding program changes.

Accept disclaimer*

I acceptI do not accept

Power of Music Registration Form

Person #1 - individual living with dementia

Person #2 - Care partner

Disclaimer