Large Group Social Event Registration

Large Group Social Event Registration

This information will be used in the event a Large Group Social event has to be rescheduled or cancelled.
Name

First NameLast Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Select the event you would like to attend.
Fall Social with Brad Boland

Date: Monday, October 19, 2026
Time: 10:30 am - 12:00 pm
Place: Trillium United Church (415 Linwell Rd, St. Catharines ON)

Description:

Join us for a cozy fall morning filled with good company, sweet treats and live music by Brad Boland!

This social event is open to all clients and care partners of the Alzheimer's Society of Niagara Region.

Limited transportation available. Please inquire upon registration.

Program made possible through the support of the Government of Ontario’s Seniors Community Grant Program.
Will you be attending with a guest?
Guest Information
Name

First NameLast 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
Are you in need of transportation to the venue? *Limited availability
Do you or your guest have any food allergies
Please describe the food allergies below
Comments:
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:
Photography / Videography Disclaimer

Photos taken may be published to our website, social media, or other material.

I acknowledge that in lieu of a professional camera, photos and/or videos may be taken by an Alzheimer Society of Niagara Region or Alzheimer Society Niagara Foundation staff member using a personal device with the sole intention of using my image for Alzheimer Society of Niagara Region or Alzheimer Society Niagara Foundation business, and not for personal use or distribution.

I also acknowledge that I may withdraw my consent at any time by contacting the Alzheimer Society of Niagara Region.
Accept Photography / Videography disclaimer:
Want to stay informed on everything the Alzheimer Society of Niagara Region provides? Subscribe to our newsletter and receive updates on our programs, events, and more!

Click here to subscribe (opens in new tab).
Should be Empty:

Large Group Social Event Registration

Guest Information