Caregiver University

Memory Impairment and Neurodegenerative Dementia Center (MIND Center)
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Caregiver University Application Form

2023 Dates:

February 7-17, 2023
May 16-26, 2023
August 15-25, 2023
November 7-17, 2023

* = Required Fields

Last Name*

First Name*

Middle Initial*

Preferred Name (what you like to be called)*

Address Line 1*

Address Line 2

City/State/Zip*

City
State
Zip Code	-

Email Address*

Primary Phone Number*

() -

Alternate Phone Number

() -

What race/ethnicity best describes you? (Please choose only one.)*American Indian / Alaskan Native
Asian / Pacific Islander
Black / African American
White / Caucasian
Multiple Ethnicities / Other (Please specify.)
Prefer not to answer

If Other, please enter here.

Please choose the answers that best describe your current dementia caregiving situation.*I provide in-home care to a relative who is living with Alzheimer's or another type of dementia
I care for my relative full-time (we live together)
I care for my relative part-time and provide intermittent care (3 times a week or less)
I provide in-home care to someone I am not related to
I am the primary caregiver
I provide care with support from siblings, in-home care professionals, or other support service
I have never used support services
I anticipate providing care to someone with Alzheimer's or another type of dementia in the near future

Please describe your current caregiving situation in 100 words or less.*

Please describe what you hope to learn or accomplish through the training.*

Please describe how you learned about Caregiver University.*

Please describe your internet access and available electronic equipment to participate in the virtual training (PC, laptop, tablet, mobile phone, webcam)*

Caregiver University is provided by The MIND (Memory Impairment and Neurodegenerative Dementia) Center at the University of Mississippi Medical Center.