UC Davis - sign up loved one

Please complete the form below to sign up your loved one. Please direct any questions to: inquiry@alzbuddies.org.

Name *
Name
Phone *
Phone
Alzheimer's Buddies will briefly contact you to confirm your loved one's registration and to extend an invitation to your local chapter's annual family event with your loved one, student volunteers, and other families.
Mailing Address *
Mailing Address
At the end of the academic semester, the student volunteer visiting your loved one will mail you a letter reflecting on their friendship with your loved one.
Your Loved One's Name *
Your Loved One's Name
This information will be shared with the student volunteer visiting your loved one. Please feel free to include your loved one's interests, especially music preferences, to help facilitate the start of their new friendship.
I would like to sign up for the Alzheimer's Buddies newsletter sent to my email address.
Photo Permission *
I give my permission for all still and moving images taken or recorded by or on behalf of National Alzheimer's Buddies or made available to National Alzheimer's Buddies of my loved one to be used in any or all of the promotional and advertising material of National Alzheimer's Buddies; and/or provided to any third party, including but not limited to media, organizations, government bodies, not-for-profit organizations and National Alzheimer's Buddies partners, for their use as they see fit.
Permission to Visit *
I, the legal guardian of my loved one, do hereby release National Alzheimer's Buddies, their local Alzheimer's Buddies chapter, and the nursing facility from any and all liability relevant to the time spent between the student volunteer and my loved one as it relates to his/her participation in the Alzheimer's Buddies program. I understand that any information regarding these visits will confidentially be kept within the confines of National Alzheimer's Buddies.