Name:
Address:
City:
State:
Zip Code:
Phone:
E-mail:
Relationship to person with dementia:
Self    Spouse    Child    Professional    Other
Person with dementia:
Age:
Gender:
Currently living:
alone    with spouse    with child    in professional care    Other
I would like to be added to the Alzheimer's Association mailing list.
I would like to receive a follow-up call from a Helpline Specialist.
I would like to receive a Resource Guide.
If yes, for which county?
Which of the following materials would you like to receive?
General Information Caregiver Guide
Activities Support Groups
Home Healthcare Assisted Living
Adult Day Care Nursing Homes with Special Care Units
Respite Care Physicians
Home Safety Elder Law Attorneys
Safe Return™ Behavioral Issues
Medications Driving
Other questions or concerns:
Alzheimer's Association of Greater Indiana takes your privacy very seriously. The information we collect helps us to improve our content, and customize content of certain pages for you. The Alzheimer’s Association does not sell, trade, or rent personal information about its Web site users.