A Gift of Time
P.O. Box 427
Georgetown, Texas 78627
info@agiftoftimegeorgetown.org
512-489-0160
pre-registration Day Out (respite) program
Participant Full Name
*
First Name
Last Name
Participant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Please Select
Married
Single
Divorced
Widow/Widower
Gender
*
Please Select
Male
Female
Prefer not to answer
Caregiver Name
*
First Name
Last Name
Caregiver Mobile Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Has the participant been diagnosed with dementia? If so, which form?
*
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Do you attend another Respite Program? Please note that preference will be given to individuals who are not already participating in other Respite programs if we have a waitlist.
*
PALS
Special Friends
Other
Please tell us a little bit about the participant.
*
Either with a Doctor's diagnosis and/or your opinion, what stage of dementia would best describe the participant? This will help us determine which of our programming would be the best fit. You may select two options if you feel like the participant may be in between these stages.
*
Mild Cognitive Impairment: Your loved one may notice memory lapses or thinking changes that are more than normal aging but not severe enough to interfere with daily life. They may forget appointments, repeat questions, or have trouble finding words, but they can still manage their personal care and live independently.
Mild Dementia: Memory and thinking problems are more noticeable and begin to affect daily life. Your loved one may need reminders for tasks like taking medications or paying bills. They may get lost in familiar places, show poor judgment, or struggle with planning but can still participate in conversations and daily routines with support.
Moderate Dementia: Memory loss and confusion are more pronounced. Your loved one may need daily help with dressing, meals, or hygiene. They may mix up relationships, have trouble with time or place, and become frustrated or withdrawn. Safety concerns may increase, and supervision is often needed.
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