Anticipated Program Opening: March 2027
Thank you for your interest in The Gathering Place. Our program follows the social model of care, focusing on social interaction, recreation, and meaningful engagement while providing caregivers with time to rest and recharge. At The Gathering Place, we will not administer medication, and participants must be able to feed themselves, use the restroom on their own, ambulate independently (with or without an assistive device), and interact comfortably and safely in a group setting. Please complete this brief form to stay connected as we prepare to launch our respite care program in March 2027. We’ll share updates on program developments and upcoming seminars on dementia, memory care, and caregiver support.
Participant Information
Participant's Full Name
*
First Name
Last Name
Participant's Date of Birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Caregiver Information
Primary Contact/Caregiver Name
*
First Name
Last Name
Relationship to Participant
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Additional Information
Beyond memory loss, does the prospective participant have any needs for support or accommodations we should know about?
Acknowledgement and Consent
Please confirm the following:
*
Submit
Should be Empty: