Anything for Alzheimer's/Coffee Break

Contact details
Organization Name
Contact Name*

First NameLast Name
Title/Position
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
E-mail*
example@example.com
About your event
Type of event planned:*

Coffee & treatsBarbecueDress down daySelling coffee cup decalsRaffleGarage saleCar washCash register round-upForeign currency collectionOther
Planned date of event:

DayMonthYear
Hour MinutesAM/PM Option
Is your event open to the public?*

YesNo
Expected attendance:
If yes, would you like our help promoting your event? (ex. Alzheimer Niagara website & social media)

YesNo
For public events and/or events with more than 15 participants
Would you like a representative from the Alzheimer Society to attend your event? (subject to availability)*

YesNo
If yes, please select from the following options. Education topics available are "Healthy Brain", "What is Dementia", and "Creating a Dementia Friendly Community"

Staff and/or Board membersMini Educational session (20-30 minutes)Educational session (up to 1 hour)
Supplies for your event

We will provide you with posters, pledge forms and tips to help you promote and run a successful event!
Please select the type of promotional kit you would like:*

Digital kit (PDF versions of poster, pledge form, event guide, etc.)Paper kit (Poster, pledge form, event guide plus a coin box)
Additional Comments:
Check this box if you would like to receive your kit in French
Enter the word as it's shown*
Should be Empty:

Contact details

About your event

For public events and/or events with more than 15 participants

Supplies for your event