LLC Registration

Name

Phone

This address will receive a confirmation email

Birth Month

Preferred Method of Communication Phone Text Email

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Care Partner's Name

Care Receivers Age

Primary Diagnosis Alzheimer's Disease Vascular Dementia Lewy Body Dementia Frontotemporal Dementia Mild Cognitive Impairment Other

Please describe your loved one's current abilities

Favorite Music

Favorite Hobbies

Any food allergies?

Dietary Preferences Vegetarian Vegan Gluten Free Diabetic Low Sodium Other

Please Share Other Options

Does either participant require accommodations? Wheelchair Walker Hearing Assistance Visual Assistance Mobility Assistance Other

Please share other accommodation needs

Medical conditions, behaviors, or concerns to be aware of

What do you hope to gain from participating in the Memory Care Café? Support Community Education Respite Friendship Resources Spiritual Encouragement

How did you hear about Us?

Friend or Family Physician Hospital Name DayBreak Adult Care East Bay Church of Religious Science Social Media Community Organization Website

Photo & Media Release Permission

I give permission for photographs/videos to be used for educational and promotional purposes.

Yes No

Liability Acknowledgment

Liability Acknowledgment: I understand that Living Love Connection Teaching Center provides community programming and is not responsible for medical care or supervision beyond the scope of the Memory Care Café program.

I acknowledge and agree

Signature of Caregiver

Description

Welcome to the Living Love Connection Memory Care Café!

Thank you for your interest in joining our community. The Memory Care Café is a welcoming place for individuals living with memory loss and their care partners to connect, learn, share, and enjoy meaningful experiences together. Please complete the registration form below so we can prepare for your visit and provide the best possible experience. We look forward to welcoming you with compassion, community, and opportunities to create moments that matter.

LLC Registration

Description

Please Fix the Following