Required fields are marked with asterisks (*)

Participant Information

Please complete the fields below to continue to program registration.

Last Name

First Name

Age on first day of program

Mailing Address

City/Town

Postal Code

Phone Number

Email Address

Would you like to receive email updates about future programs?

Yes

Do you have any allergy/medical/general health concerns that program staff should be aware of?

Yes

Care Partner Information

The Minds in Motion program is designed for individuals experiencing early to mid-stages of dementia and their care partners (spouse, sibling, child, etc.). Please fill out the info below for the care partner who will be attending the program.

Last Name

First Name

Age on first day of program

Is your contact information (email, address, phone number etc.) the same as above?

Yes

Do you have any allergy/medical/general health concerns that program staff should be aware of?

Yes