Crater Caregiver Coalition

Virginia Caregiver Coalition

Please complete the following information to keep on file as we network, grow, and find our strengths.

9:30 A.M. – NOON at Charlottesville Health Department 2010 July 15; September 16; November 18; 2011 January 20; March 17, May 19

Scheduler Annie Marrs, [email protected] or 434-973-6122 Alzheimer's Association, Central & Western VA

Type of Membership (check one) Organization:___ or Individual: ___

Name of agency (if applicable):

Website: ______

Your name:

Professional title: ______

Family Caregiver: _____Yes _____No Contact information Address

Phone Number

E-mail address

In your view, and the view of your agency, what issues face the family caregiver today?

What services does your organization provide to help the family caregiver?

What strengths do you bring as an individual?

What would you like to see the coalition focus on in the next year?

In the long-term?

What organizations, skills, or talents do you think need to be included in the coalition?

Should I be invited to join the Virginia Caregiver Coalition, I will meet the following expectations:

 I agree to serve as a working member of the Virginia Caregiver Coalition, participating in committees and other work groups.  I agree to attend all meetings to the best of my ability and inform the executive committee chair if unable to attend.  I agree to educate and inform other coalition members of events in my community or other pertinent caregiver information.  I agree to provide written and verbal notice to the Executive Committee should I choose to withdraw from the coalition. If I am an organizational member, I agree to find a suitable member to represent my organization in my place.

Printed Name: ______

Signature: ______

Date: ______

Virginia Caregiver Coalition Ellen M. Nau, Chair Virginia Department for the Aging [email protected] 1610 Forest Avenue Suite 110 804-662-9340 Richmond, VA 23229