Stories in the Moment ONLINE - Registration Form

Registration Form for Stories in the Moment Dance Program ONLINE

Please note that the Stories in the Moment program is designed for individuals living with dementia or MCI and/or their care partners ONLY.
If you are a care partner registering on behalf of someone living with dementia or MCI, provide the details for the person living with dementia and then enter your information under "Care Partner information".

If you are interested in training to facilitate this program or in hosting an in person program in your community, contact us at magda@dancestreamprojects.com.
Are you a person living with dementia and/or MCI or a care partner?
Please select one*

Person living with dementia and/or MCICare partner
Person living with dementia information:
Name*

First NameLast Name
Email*
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Care partner information:
Care Partner Name

First NameLast Name
Care Partner Email
Care Partner Phone Number

Area CodePhone Number
Care Partner Address

Street Address

Street Address Line 2

CityState

Zip Code
If you are a care partner filling out this form on behalf of another person, what is your relationship? (Optional)
For example: Son, daughter, husband, wife, partner
Please let us know if you have any questions.
Which Online Program Would You Like To Join?
Please select all options that interest you

Stories in the Moment - Thursdays (11am PT/1pm CT/2pm ET)Stories in the Moment - Fridays (1pm PT/3pm CT/4pm ET)
Thank you for your interest in the Stories in the Moment online dance program!
- Once you complete this form, you will see a welcome message and email confirming your registration.
- You will receive an email with the ZOOM link to join the day before and morning of each program.
Questions? Contact Magda Kaczmarska at magda@dancestreamprojects.com.

We look forward to dancing with you!
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Registration Form for Stories in the Moment Dance Program ONLINE

Are you a person living with dementia and/or MCI or a care partner?

Person living with dementia information:

Care partner information:

Which Online Program Would You Like To Join?