Dementia Conversations – Sign Up!Mondays, 10:00 – 11:30 AM Pacific via ZoomName(Required) First Last Email(Required) Phone(Required)Event Date CityState/Province(Required)Zip/Postal Code(Required)Country/Region(Required)OrganizationJob TitleAre you a person living with dementia? Yes NoAre you a care partner, family member, or friend of someone living with dementia? Yes NoDo you live or work in Nevada, or provide care and support to someone living with dementia in Nevada?(Required) Yes NoAgeRace/Ethnicity (select all that apply) American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White OtherOther race/ethnicity (please describe)Gender Identity Female Male Non-Binary Prefer to self-describeGender identity (please self-describe)Professional Affiliation (select all that apply) Healthcare Provider First Responder Social Worker Community Group Adult Day Services Aging Services Assisted Living Caregiver Support Programs Hospice Residential Memory Care Respite Services OtherOther professional affiliation (please describe)Healthcare Provider: please select your primary affiliation(s) (select all that apply) Family Medicine Internal Medicine Risk Factor Specialties Nurse Practitioner Geriatrician Emergency Response CNA Nurse Occupational Therapy Physical Therapy Dental Home Health Aide OtherOther healthcare affiliation (please describe)Do you live or work in a rural community? Yes NoAre you a student enrolled in either part-time or full-time undergraduate or graduate education? Yes NoDo you serve or have you ever served in the U.S. Armed Forces? Yes NoAre you living with an intellectual and/or developmental disability? Yes No
