Alzheimer’s & Dementia Support Registration | First United Methodist Church of Fort Worth

Name*

First Last

Phone*

Email*

City*

Sign me up for:

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Legal & Financial Planning (September 30 or October 3, 2021)

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Which event will you attend?

Thursday, September 30 at 10:00 am
Sunday, October 3 at 12:15 pm

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Will you need a lunch?

Yes — Pay online
Yes — Pay at door
No

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How many lunches will you need?

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Advance Directives Workshop (October 14 or 17, 2021)

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Which event will you attend?

Thursday, October 14 at 10:00 am
Sunday, October 17 at 12:15 pm

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Will you need a lunch?

Yes — Pay online
Yes — Pay at door
No

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How many lunches will you need?

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What Your Phone Can Do For You (November 4 or 14, 2021)

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Which event will you attend?

Thursday, November 4 at 10:00 am
Sunday, November 14 at 12:15 pm

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Will you need a lunch?

Yes — Pay online
Yes — Pay at door
No

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How many lunches will you need?

5th Street Cafe Dementia Friendly Social Club (Wednesdays)

Activities for People Living at Home with Dementia

Gender*

Male
Female

Ethnicity*

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Age*

Zip Code*

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Alzheimer’s & Dementia Support

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