Community Memory Screening

Sign Up to be a Community Memory Screening Site

Please complete this form to register to be a Community Memory Screenings site. Fields marked with * are required. Your registration will be reviewed and posted to our Web site listing for this event. If there are any concerns with your registration, we will contact you prior to posting your information on the Web site.

AFA provides all the necessary tools - at no cost - to seamlessly and effectively carry out the memory screenings. Please allow several business days for your registration to be processed.

General Information

Organization: *
Contact Name: *
Title:
Address: *
City: *
State/Province:
Zip Code: *
Country: *
Type of Organization *
Phone: * Format as XXX-XXX-XXXX
Extension: (Numbers Only)
Email: *
Fax: Format as XXX-XXX-XXXX

Web Site Listing Information

Location of Screening - Use Address information from above or fill in fields if Screening Location is different than above.
Address:
City:
State/Province:
Country: *
Zip Code:
Type of Venue:
For Information, Call: Format as XXX-XXX-XXXX
Extension: (Numbers Only)

 

Web Site:
Screening Date Type: (ex: “1/1/2009”)
(ex: “First Thursday of Each Month”)
Screening Date: * (Format as 01/01/2010) *
Screening Time: *

Screenings will be provided in the following languages (check all that apply): *




Other

If you would like to receive any of the following AFA information, please check the box or boxes that apply:





 

National Memory Screening Day
National Memory Screening Day
National Memory Screening Day
National Memory Screening Day

View Alzheimer’s Foundation of America’s Web sites:

AFA | AFA Teens | AFA Quilt to Remember | Candle Lighting | care ADvantage | Care Professionals | Excellence in Care | Prevention

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