Enter the name of the person with dementia here. Your reservation will be held under this name.
Include a contact phone number so we may contact you with any additional questions we may have.
A confirmation message will be sent to the email address that you provide here.
Enter the name of the family member or care partner here. If any additional guests will be attending, fill their names in the spaces provided below.
This will help us determine how many participants will be attending this program.
Include your address if you would like to be added to our mailing list for this program.