Dementia Education Series Registration

Dementia Education Series

This information will be used in the event a Dementia Education Series: Next Steps & Care Essentials session has to be rescheduled or cancelled. Please complete this form once for each person who will attend the learning series.
Select the date of the session you are registering for. All Online sessions will be held via Zoom.*

October 1, 8, 15 & 22, 2025 (In Person at the St. Catharines Public Library, Dr. Huq Family Library Branch from 1:30 - 3:30 pm)November 12, 19, 26 & December 3, 2025 (In Person at the Fort Erie Public Library, Centennial Branch from 1:30 - 3:30 pm)February 4, 11, 18, 25 (In person at the Welland Public Library, Seaway Mall Branch from 1:30 - 3:30pm)April 1, 8, 15, 22 (In Person at the St. Catharines Public Library, Dr. Huq Family Library Branch from 1:30 - 3:30 pm)
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Cell Phone
Home Phone
E-mail*
example@example.com
Are you a returning friend who has registered for an Alzheimer Society of Niagara Region program in the past (including Next Steps and Care Essentials)?*

YesNoUnsure
The Alzheimer Society Niagara Region is committed to providing the highest quality of support and services to our community. To help us understand better the population we serve, we are requesting additional demographic information. Gathering this information not only helps us tailor our programs to meet the unique needs of our community, but it also plays a crucial role in our ability to apply for and receive funding through Ontario Health and private grants, which require detailed demographic data to support our initiatives. As a healthcare custodian, we are responsible for collecting, managing, and protecting this information in compliance with all applicable privacy standards. Your participation in providing this data helps ensure that we can continue delivering effective, person-centered care to those impacted by dementia.

If you prefer not to answer a specific question, you may choose that option in the questions drop box.
Language Spoken at Home
Mother Tongue
Gender
Racial or Ethnic Group
Birthdate

MonthDayYear
Date
Health Card Number
Health Card Version
Comments:
Should be Empty: