If you are interested in becoming an advocate, and want to learn
more about how you can make a difference, please print this
page, fill out the information below and return it to the address
listed at the bottom of this page. Any information you share
with us will be kept completely confidential.
Your
relationship to the person with Alzheimer's disease:
__Spouse
__Sibling __Child __Other Relative __Self __Professional Caregiver
Are
you the primary caregiver?
__Yes __No
Do
you live with the person with Alzheimer's disease?
__Yes __No
Have
you used any of the following services?
__Adult
Day Care __Long Term Care Facility (Nursing Home) __Respite
Care __Assisted Living __Home Care __Support Group __Other___________________
With
help and support from the Alzheimer's Association, I am willing
to:
__Contact
my state or federal representatives
__Visit
my legislators with a group of advocates
__Testify
about my experiences to legislators
__Tell
my experiences to the media
__Share
my story with members of the Alzheimer's Association
Name__________________________________________________
Address________________________________________________
City___________State_____Zip_____
Email_________________
Day
Phone_________________
Evening Phone__________________
Please
return this form to:
Alzheimer's Association
196 Princeton-Hightstown Road, Bldg. 2, Suite 11
Princeton Junction, New Jersey 08550
Fax: (609) 275-1182
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