Dementia Caregiver Online Support Group Consent

Information About You
While personal information and details are kept confidential, non-identifying information may be used for grant writing purposes. Your cooperation assists in obtaining funding that in turn allows ourservices to be provided at low or no cost.
Name*
First Last
Email*
Phone*
Zip Code / County*
Who are you caregiving for and how long ago were they diagnosed with dementia or a memory issue?*
Do you have any questions or concerns regarding the online support group?
Disclaimer: The Edel Caregiver Institute (ECI) caregiver support group is intended for peer-to-peer information sharing among family caregivers. The facilitators are not liable for information shared and use of such information is the sole responsibility of the participating caregiver. Information should be verified by a healthcare provider as it is peer-to-peer not expert advice. The caregiver assumes all responsibility of how any information is used. All participants also agree to respect the confidentiality of the support group and fellow participants. Please include your name in box below to denote agreement and signature.*
Phone
This field is for validation purposes and should be left unchanged.

Information About You