Your Name *

First Name

Last Name

Picture with Buddy? *

We highly encourage you to submit a picture of yourself with your buddy to help us put faces to the story! If you choose to submit a picture, please email it to inquiry@alzbuddies.edu along with your name. Please be sure to check that your Buddy has signed a photo release form, which gives you permission to share their information and use their photo.

I have emailed a picture with my buddy to inquiry@alzbuddies.org.

I will not be submitting a picture with my buddy.