To Whom I May Concern® -- Creating Connections -- Spring 2025

Creating Connections: Dementia Support Group Facilitator Training

Tuesday, May 20 & Wednesday, May 21 (6 - 8 pm ET each day)
Course Date Preference:

Tuesday, May 20 & Wednesday, May 21 (6 - 8 pm ET each day)Wednesday, May 28, 2025 (11 am - 3 pm ET)
Personal Information
Full Name*

PrefixFirst NameLast Name
Organization
Your Position
E-mail*
Phone Number*

Country Code (e.g. 1)Area CodePhone Number
Mobile Number (if different from above)

Country Code (e.g. 1)Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please help us get to know you by telling us about yourself
Do you currently or have you previously facilitated a support group for people living with dementia?

YesNoOther
Please tell us about your experience facilitating a support group or other group:
Please tell us about your current or past work with people living with dementia or care partners (volunteer or professionally):
Why would you like to take this course?
Additional Trainees from the Same Organization

If five or more people from your organization would like to take the training together, please contact laura@towhomimayconcern.org to arrange for a private training session.
1st Additional Trainee

PrefixFirst NameLast Name
Position
E-mail
2nd Additional Trainee

First NameLast Name
Position
E-mail
3rd Additional Trainee

First NameLast Name
Position
E-mail
example@example.com
Payment
Please choose one of the following payment options:*

Invoice my organization (If you select this option, please do not select a registration fee below)Payment via PayPal (includes credit card option)
If you would like us to invoice your organization, below please enter the company name, address and to whom the invoice should be addressed AND their email address. Please indicate the number of registrations from your organization.

Please choose one of the following options. Payment is processed through PayPal.

Registration Fee:$299.00

Fee for one person

2 people from same organization$540.00

3 people from same organization:$810.00

4 people from same organization:$1,080.00

Enter coupon

Total $0.00

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Creating Connections: Dementia Support Group Facilitator Training