Request Form

Request Form

to participate in Project Sue
Your Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2 (optional)

CityState

Zip Code
Shipping Address(if different)

Street Address

Street Address Line 2 (optional)

CityState

Zip Code
Phone Number*
E-mail*
example@example.com
Type of Phone Number

LandlineMobile (if OK to text)
Name of afflicted loved one

First NameLast Name (optional)
Date of diagnosis

MonthDayYear
Date (optional)
TERMS AND CONDITIONS

After receiving the recorder, I agree to make a recording in a timely manner (1-2 weeks) and return the recorder in the postage paid envelope as soon as possible.

Recorders are provided FREE to individuals and families affected by Alzheimer’s Disease with the understanding and consent of the requestor that the recorder will be used in accordance with the mission of Project Sue and not for any other purpose. In addition, I agree to hold harmless Project Sue and its owners and staff from any liability for damage or harm caused by participation in Project Sue.

I agree to give Project Sue all rights to use my recording to help other people affected by Alzheimer’s, if needed, without any type of compensation.
DISCLAIMER

Upon receiving your request, we will send you a complimentary recorder with instructions for its use asap. We will include a postage paid envelope for its return as well. We request that you make a recording and return the recorder as soon as possible so we can include your recording in Project Sue. Don't stress over the length or quality of your recording. We have tried to make the process as easy as possible with clear and simple instructions, however, feel free to contact us with any questions you may have.

Since we are relying on the United States Postal Service to deliver recorders, Project Sue cannot guarantee safe delivery of recorders or other materials. We apologize for the inconvenience.

How did you hear about us?
Please Specify
Feedback about us:
Be honest, we know we aren't perfect!

Please give reference of any people whom you feel need to know about us:

	Full Name	Address	Contact Number
1
2

SUPPORT AND DONATIONS

Please help us continue Project Sue, if you can!
Project Sue is a 501c3/Non-profit organization, therefore, donations may be tax deductible.

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Request Form

SUPPORT AND DONATIONS