Registration Form: Community Listening Session on Brain Health

Event Date: Monday, April 17, 2023

Event Time: 5:00 pm to 7:00 pm

Event Address: 2014 W Third Street, Duluth, MN 55806

This building is the former Lincoln Park Community Center and is currently the home of Ecolibrium3 offices.

Please join us for a community conversation about brain health. We will provide basic information about memory loss, dementia, and Alzheimer’s. Most importantly, we want to hear from you about how we can help support families who have dealt with or are dealing with dementia in our community.

We will provide a light dinner free of charge.

Thank you for answering the following questions to help us plan for this event.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Your Postal / Zip Code*

example: 55806

Are you a family or friend caregiver for someone living with memory loss, Alzheimer’s disease, or other dementia? (Family or friend caregiver refers to someone providing care for someone outside of the healthcare or other professional caregiver setting.)*

YesNoNot sureI provide care for someone else, but they do not have memory loss, Alzheimer’s disease, or other dementiaI provide care for more than one person

Optional: If you answered yes to the previous question, are you caring for your spouse, parent, grandparent, child, friend, or neighbor? Please describe.

Are you concerned about or know a friend, neighbor, or loved one that may be experiencing memory loss or dementia?*

YesNoNot sure

For the meal provided: Do you have any dietary restrictions?*

YesNo

For the meal provided: If you answered yes to the previous question, please describe your dietary restrictions.

Please verify that you are human*

Registration Form: Community Listening Session on Brain Health - April 17, 2023