If you are interested in becoming an advocate, and want to learn more about how you can make a difference, please print this page, fill out the information below and return it to the address listed at the bottom of this page. Any information you share with us will be kept completely confidential.

Your relationship to the person with Alzheimer's disease:

__Spouse

__Sibling

__Child

__Other Relative

__Self

__Professional Caregiver

Are you the primary caregiver?
__Yes __No

Do you live with the person with Alzheimer's disease?
__Yes __No

Have you used any of the following services?

__Adult Day Care

__Long Term Care Facility (Nursing Home)

__Respite Care

__Assisted Living

__Home Care

__Support Group

__Other___________________

With help and support from the Alzheimer's Association, I am willing to:

__Contact my state or federal representatives

__Visit my legislators with a group of advocates

__Testify about my experiences to legislators

__Tell my experiences to the media

__Share my story with members of the Alzheimer's Association

Name__________________________________________________

Address________________________________________________

City___________State_____Zip_____

E-mail_________________

Day Phone_________________

Evening Phone__________________

Please mail this form to:
Alzheimer's Association
196 Princeton-Hightstown Road, Bldg. 2, Suite 11
Princeton Junction, New Jersey 08550

Or fax to: 609.275.1182