Sign up to be a Screening Site -

National Memory Screening Day - Tuesday, November 13, 2012

Please complete this form to register to be a National Memory Screening Day site for 2012. 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 on National Memory Screening Day. You will be responsible for selecting a qualified healthcare professional screener—a physician, nurse, social worker, etc.—to administer the tests. AFA does not provide screeners. We will send you a link to a secure Web site that lists most materials, and we will send additional materials via the mail. Please allow several business days for your registration to be processed. If you have registered for NMSD and you do not receive your link to the secure Internet site or the materials via mail, please contact info@nationalmemoryscreening.org.

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 Time:
Screening Date: (if other than Tuesday, November 13, 2012)

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:





IMPORTANT: by clicking "Register," you are agreeing to be a participating site for National Memory Screening Day 2012. Your event details will be posted to www.nationalmemoryscreening.org in the fall of 2012. Please be prepared for your organization to receive phone calls about this event.

 

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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