Name *

First Name

Last Name

Phone *

Alzheimer's Buddies will briefly contact you to confirm your loved one's registration and to extend an invitation to your local chapter's annual family event with your loved one, student volunteers, and other families.

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Mailing Address *

At the end of the academic semester, the student volunteer visiting your loved one will mail you a letter reflecting on their friendship with your loved one.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Loved One's Name *

First Name

Last Name

Photo Permission *

I give my permission for all still and moving images taken or recorded by or on behalf of National Alzheimer's Buddies or made available to National Alzheimer's Buddies of my loved one to be used in any or all of the promotional and advertising material of National Alzheimer's Buddies; and/or provided to any third party, including but not limited to media, organizations, government bodies, not-for-profit organizations and National Alzheimer's Buddies partners, for their use as they see fit.

I agree to these terms.

I do not agree to these terms.

Permission to Visit *

I, the legal guardian of my loved one, do hereby release National Alzheimer's Buddies, their local Alzheimer's Buddies chapter, and the nursing facility from any and all liability relevant to the time spent between the student volunteer and my loved one as it relates to his/her participation in the Alzheimer's Buddies program. I understand that any information regarding these visits will confidentially be kept within the confines of National Alzheimer's Buddies.

I agree to these terms and give Alzheimer's Buddies permission to visit my loved one.