PUERTO RICO ALZHEIMER DISEASE AND RELATED DISORDERS ASSOCIATION

APPLICATION FOR MEMBERSHIP

Please print this page, fill in all the blanks, and send your membership fee to the above address. This information is very important in order to send you the "Informative Bulletin" and to invite you to our activities. Our patients count on us.

Soon we will have this application available electronically.

1.

Name

________________________

Paternal Last Name

________________________

Maternal Last Name

________________________

2.

Home Address

____________________________________________

____________________________________________

City

__________________________

State

__________________________

Zip Code

__________________

Country

___________________________

3.

Postal Address

____________________________________________

____________________________________________

City

__________________________

State

__________________________

Zip Code

__________________

Country

___________________________

4.

Home Phone

___________________ Work_________________

5.

E-mail

___________________

6.

Ocupation

___________________________________________

7.

Place of Work

___________________________________________

8.

Do you know anyone with Alzheimer's Disease? Yes / No

Relationship

________________________

9.

How Long?

___________

Patient's Age

___

Sex

___

10.

Does this patient receive medical treatment? Yes / No

11.

Indicate which professional: Geriatric Doctor / Family Doctor / Neurologist / Psychiatrist/ Other

12.

The most urgent help that is needed to care for this patient. Explain.

Economic Help

Medical Help

Home Care

Nutrition

Others

_________________________________

13.

Would you like to cooperate with the Association with volunteer work? Yes / No

Tasks to perform

__________________

14.

Do you have a computer or access to the Internet? Yes / No

ANNUAL MEMBERSHIP $15.00
PLEASE DO NOT SEND CASH IN THE MAIL. THANK YOU.

Please send any suggestion, comment or problem to
maryannsch@hotmail.com

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