Register as Champion - Dementia Friends PA

CHAMPION PROFILEYou must have completed a Champion Training Class prior to registering.

* Required field (optional)

Demographic Explanation (optional)

Thank you for your interest in becoming a Dementia Friend Champion! When you register 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 This email address is being protected from spambots. You need JavaScript enabled to view it..

Date of Champion Training * (optional)

Username *

First Name *

Last name *

Email Address *

Please use a valid mail address

Confirm Email Address *

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Password *

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Confirm your password *

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Address Line 1 *

Address Line 2 (optional)

City *

State *

Zip Code *

County *

What counties are you willing to serve as a Dementia Friends Champion? (Please check all that apply) *

Which category includes your age? *

What category best describes your race? *

Are you Hispanic or Latino/a? *

How do you describe your current gender? *

Do you think of yourself as: *

Which of the following best describes the sector you represent? *

Why do you want to volunteer as a Dementia Friend Champion? *

Are you interested in learning more about how to start a Dementia Friendly Community in your area? *

We are looking for Champions who are interested in working with us to deliver the Dementia Friends curriculum to community members whose primary language is not English. If you are multilingual, would you be interested in collaborating with us to offer *

Please list the languages in which you are proficient: (optional)

I agree to not modify the Dementia Friends Pennsylvania logo or materials without consent. *

Yes I agree.

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