- Person may be nominated by self, by a community healthcare professional, or Alzheimer's Association leadership
- Person must have the ability to participate in conference calls
- Person must have the ability to travel to Chicago for face-to-face meeting, if necessary. (The association will cover expenses.)
- Term is 1 year
Print Name: _________________________________________
Address: ____________________________________________
City, State, Zip: ______________________________________
Phone: _____________________________________________
E-mail (if available): ___________________________________
Communication preference (indicate 1 st, 2 nd, 3 rd choices): US mail _____ e-mail _____ phone _____
Diagnosis: __________________________________ Date given diagnosis: _______________________
Diagnosis was made by whom/where: _______________________________________________________
Chapter affiliation: ____________________________________
Have you ever participated in chapter activities (programs, advocacy events, or fundraising events) and, if so, how? _________________________________________________________________________________
______________________________________________________________________________________
If travel to Chicago is involved for face-to-face meeting:
Name of travel companion: ______________________ Relationship: _________________________
Companion’s address: __________________________________________
City, State, Zip: __________________________________________
Companion’s phone: ___________________________ E-mail: _____________________________
Why do you want to participate in this Advisory Group? _______________________________________
______________________________________________________________________________________
__________________________________________________________________________________
Yes, I understand the role of the Advisory Group of People with Dementia is to provide input to the Alzheimer's Association for future planning on issues related to persons living with early stage dementia.
Signature of Nominee: ___________________________________________
Signature from affiliated chapter: ___________________________________
Nominator, if other than self: (print) ________________________, (sign) _________________________
