* 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.
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.
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.