Memory Cafe Healing Headsets Application Form

Thank you for your interest!! If you become a recipient, the only "COST" for The Healing Headset project is to share: +testimonials +pictures or +video with the help of yourself & their familiy. A consent will be provided & we know that not everyone will agree but we need your help with those that are willing in order to grow our program. Saying "YES" also means you are willing to do 2 Zoom calls to learn about tips & tricks.*

YesNo

Which state is your Cafe located in?

Continental U.S. Only.

Cafe Leader's Full Name*

First NameLast Name

Memory Cafe Name*

If located inside a larger organization ie..public library, list this organization or building name as well. Avoid P.O. boxes since this is the address we use to ship headsets to those who are approved.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

E-mail*

example@example.com

Website

How often do you meet?*

monthlyweeklyOther

The cafe leader is the POINT person. They connect members with our music form (via our link or a printed version) & give tips on completing & returning. All headsets will be shipped to this lead person. You will need to distribute them as soon as possible. You will demonstrate the ease of operating & remind them of our tutorial videos. If a member becomes inactive before they receive, the leader is asked to return headset to our offices (contact us for shipping label). Do you agree to performing this role?

This is year 16 of providing this type of service. We try to make this VERY SIMPLE!!

Over the last 4 months, what is an average # of attendees at a cafe?

What year was your cafe launched? What makes your cafe special & why did you apply today? Include any other services that might be asoociated such as a support group or at-home kits to ease the home caring? How is music used now at your cafe? REQUIRED: Your are limited to 6 free units. How will you decide whom to offer these to? (More are available for purchase $28/each)*

If you chose to print this, be sure to submit completion to willenborgkelly@gmail.com