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Event Registration Form
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Gallatin Senior Center
Caregiver Support Series
Community Health Worker Program
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Quick Sign-In
(Takes less than 30 seconds)
*
*
*
*
*
Are you a caregiver?
*
Are you a caregiver?
A
Yes — I care for a family member or friend
B
No — I am interested in the program
C
I am here for someone else
Would you like someone to contact you about
caregiver support services?
*
Would you like someone to contact you aboutcaregiver support services?
A
Yes
B
No
Who are you caring for?
*
Who are you caring for?
A
Parent
B
Spouse
C
Other Relative
D
Friend
E
Not currently caregiving
Does the person you care for have
memory loss or dementia?
*
Does the person you care for havememory loss or dementia?
A
Yes
B
No
C
Not Sure
How did you hear about this event?
*
How did you hear about this event?
A
Senior Center
B
Church / Faith Community
C
Doctor / Healthcare Provider
D
Friend or Family
E
Social Media
F
Other
Register
