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Shaler Library
1822 Mt. Royal Blvd., Glenshaw, Pennsylvania 15116
Dementia Friends Information Session
Date:
Friday, January 03, 2025
Time:
10:30am-11:30am
Facilitator:
Joyce Mangis and Ing Kalchthaler
Class Information:
Email Address
*
Attendee Name
*
Phone Number
*
County
*
-- Please Select --
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Elk
Erie
Fayette
Forest
Franklin
Fulton
Greene
Huntingdon
Indiana
Jefferson
Juniata
Lackawanna
Lancaster
Lawrence
Lebanon
Lehigh
Luzerne
Lycoming
McKean
Mercer
Mifflin
Monroe
Montgomery
Montour
Northampton
Northumberland
Perry
Philadelphia
Pike
Potter
Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
Thank you for your interest in becoming a Dementia Friend! Below you will be asked to answer a few demographic questions. The goal of the questions is to gain a better understanding of how we can be more inclusive of all community members in Pennsylvania. All responses will be kept confidential. If you have questions or concerns about the registration, you can contact
info@dementiafriendspa.org
.
Which category includes your age?
*
-- Please Select --
9 and younger
10-12
13-18
19-29
30-39
40-49
50-59
60-69
70 and older
Prefer not to answer
What category best describes your race?
*
-- Please Select --
American Indian / Alaska Native
Asian
Black or African American
Native Hawaiian / Other Pacific Islander
White
Biracial/Multiracial
Prefer not to answer
Are you Hispanic or Latino/a?
*
-- Please Select --
Yes
No
Prefer not to answer
How do you describe your current gender?
*
-- Please Select --
Male
Female
Transgender
Non-Binary
Do not identify as female, male, or transgender
Prefer not to answer
Do you think of yourself as:
*
-- Please Select --
Bisexual
Gay or lesbian
Straight/heterosexual
Queer or sexually fluid
Prefer not to answer
Which of the following best describes the sector you represent?
*
-- Please Select --
Arts and Culture
Bank or Financial Services
Business
Civic Club
Community-based Services and Supports
Education
Faith
Government
Home Care
Hospice
Hospital
Legal and Advanced Planning Services
Library
Long-Term Acute Care (LTAC)
Long-Term Care Facility
Neighbors and Community Members
Other
Parks and Recreation
Prefer not to answer
Primary Care
Public Safety (Police, EMS, Fire, etc.)
Rehabilitation Services
Residential and Specialty Care
Youth/Teens