Maintaining Memory Skills Registration Form
Fill out the form carefully for registration
Name
*
First Name
Middle Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Mobile Number
*
Format: (000) 000-0000.
Have you received a diagnosis of Mild Cognitive Impairment? If so, when?
*
Yes
No
Date of Diagnosis and any other information you would like to share.
*
Which program(s) interests you?
*
Maintaining Memory Skills Mondays 10:00- 12:00 with optional sack lunch until 1:00
Maintaining Memory Skills Support Group Fridays 12:30 to 2:30
What type of program interests you?
*
Light exercise (chair yoga, tai chi, stretching)
Lifelong Learning (in person courses- various topics)
Arts and crafts
Board games
Puzzles, brain games, trivia
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Comments
Submit
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