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: *
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:
Location Phone: Format as XXX-XXX-XXXX
Extension: (Numbers Only)

 

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

 

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

For more information about healthy lifestyles, click here.