Dementia Caregiver Application

Name *

First

Last

Email *

Relationship to person with dementia: (I am their...)

Primary Unpaid Caregiver Profile

I provide care weekly or more (daily)
I assist my care receiver with Activities of Daily Living (ADLs)-bathing, grooming, toileting, dressing, eating, positioning, or transferring
I am employed but have had my employment affected by caregiving responsibilities
I have quit or lost employment due to caregiving responsibilities
I am solely repsonsible for caregiving responsibilities
I am also proving care to another individual (including children)
I have a chronic health condition or have has a recent health crisis
The stress or burden of caregiving is the primary need I wish to address

Terms and Agreement *

I understand and agree to the terms.

In checking the box above, you agree and confirm that all community service reports are true and accurate. You acknowledge that your service advisor may reach out to the location to confirm your participation.

Dementia Caregiver Application

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