PLEASE USE NEW JOTFORM, available at: http://bit.ly/jotformSJ
As of Tue, Feb 20, 2018 there is a new Jotform link for San Jose. We moved the form over to google sheets since it has some better features for data entry, so that's why it looks a little different, though the questions are the same! I recommend bookmarking the new jotform on your browser if you plan/ present education programs in the San Jose area. Heather also updated the 'Bay Area Education Forms and Tracking 101' doc on Google Drive (http://bit.ly/EdForms101). As a reminder, there's a different jotform for education events in San Francisco and the East Bay. These forms are forwarded to Blanca, Katie and Mary, respectively, and they create your event listing on Personify/CRM. It's critical to enter your events ASAP, so that if constituents call the contact center, we're all on the same page about what events are happening where and when. Let Heather, Blanca, Katie, Mary or Pauline know if you have any questions.
General Information:
Name of Individual Completing Jotform
*
Speaker's Name
*
Speaker's Email
*
example@example.com
Speaker's Zip Code (zip of office is fine)
*
Is this presentation open to the public?
*
Yes
No
Common Programs
*
Please Select
Know the 10 Signs: Early Detection Matters
The Basics: Memory Loss, Dementia and Alzheimer’s Disease
Conversations about Dementia
Healthy Living for Your Brain and Body
Effective Communication Strategies
Understanding and Responding to Dementia-Related Behavior
Legal Planning for Alzheimer’s Disease
Financial Planning for Alzheimer's Disease
Living with Alzheimer’s: for people with Alzheimer’s (early stage)
Living with Alzheimer’s: for caregivers- early stage
Living with Alzheimer’s: for caregivers- middle stage
Living with Alzheimer’s: for caregivers- late stage
Partnering with your Doctor
Other
N/A
National programs
Chapter Programs
*
Please Select
Getting Connected: Alzheimer’s Association Programs & Services
Research Updates: Latest in Alzheimer’s Treatment and Research
Medical and Health Providers Education
Healthy Body, Healthy Brain
Maximize your Memory: Tips and Strategies
Compassionate Communication: Connecting with a Person with Alzheimer’s
Compassionate Communication: Connecting with a Person with Alzheimer’s and Responding to Challenging Behaviors
Moving a Loved One with Memory Loss: Choices, Challenges & Considerations
SAVVY Caregiver
Other
N/A
Programs developed by our chapter
Other
If you filled out 'Other' above, please include a Presentation Description:
Delivery Method
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In-person
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Audience
*
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Medical Professionals
Professionals (other)
People with dementia
Caregivers
Care partners and people with dementia
Younger onset people with dementia and care partners
General public
Other - more information below
Other audience (please make a note if any medical or health providers were present)
Is this program specific to Early Stage individuals?
*
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Yes
No
Availability Information:
Start Date
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Day
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Day of the Week
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Tuesday
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End Date
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Day
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Start Time
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1
2
3
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9
10
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:
Hour
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45
Minutes
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AM/PM Option
End Time
*
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2
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4
5
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7
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9
10
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:
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Recurring?
*
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No
Name of Location
Address
Address 2
City
Zip Code
*
Wheelchair accessible?
*
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Yes
No
Unknown, please call to inquire.
Contact Name for RSVP or Questions
*
Title
Organization
*
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Language(s)
*
English
Spanish
Mandarin
Cantonese
Japanese
Korean
Other Language
Additional Information
Additional Information URL
Registration Required?
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Yes
No
Type of Registration
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Register online only
Register by phone only
Register online and by phone
Registration Opens
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Registration Deadline
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Walk-in Registration?
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Other Instructions
Payment Information:
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Cost
Free
Payment Instructions
Donations accepted and appreciated!
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