Sign up to be a Screening Site -

National Memory Screening Day - November 16, 2010

Please complete this form to register to be a National Memory Screening Day site for 2010. Fields marked with * are required. Your registration will be reviewed and posted in early fall 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. In the fall, we will send you a link to a secure Web site that lists most materials and we will send additonal 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: * If Other
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:
Zip Code:
Location Phone: Format as XXX-XXX-XXXX
Extension: (Numbers Only)

 

Screening Time:
Web site:

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

For more information about healthy lifestyles, click here.