Online Form Brief s1

Supporter Application Form

Dementia Action Alliance Supporter Application Form This type of membership is for organisations that may be supportive of creating a local alliance to become a dementia friendly community, but may not be in a position to become a full member of the Dementia Action Alliance and submit an action plan. Your organisation can only become a supporter if a Local DAA already exists in your area.

Once your application has been approved, your organisation will be listed on www.dementiaaction.org.uk under your local alliance webpage as a ‘Supporter’.

Information about you and your organisation The organisation listed below agrees to sign up to the National Dementia Declaration and commit to becoming a Supporter of the Dementia Action Alliance. By becoming a Supporter, your organisation agrees to raise awareness of dementia and/or support people with dementia and their carers. Please tick [ ]

Fill in your contact details

Name of organisation: Young’s Seafood Ltd Contact name: Cheryl Atkin Work address: Ross House, Wickham Road, Grimsby, North East Lincolnshire, DN31 3SW

Phone: 01472 585411 Email: [email protected] Website: Are you willing for us to share your contact details with fellow Dementia Action Alliance members: Yes [ √ ] No [ ]

Local Dementia Action Alliance you want to support: North East Lincolnshire

During 2014/2015, the organisation listed above agrees to carry out the following activities: (Please select at least one option from each of the four categories)

1. Raise awareness of dementia to staff Please tick  Encourage all staff to watch the Dementia Friends film at √ www.dementiafriends.org.uk or attend a face to face Dementia Friends session  Encourage all staff to participate in the SCIE eLearning resources √ www.scie.org.uk/publications/elearning/  Provide an alternative dementia awareness course. Please specify: 2. Improve customer service and dementia friendly ways of working  Provide staff with access to the Alzheimer’s Society Customer Facing √ Staff Guide. Details can be found at www.alzheimers.org.uk/site/scripts/news_article.php?newsID=1935

1 Supporter Application Form

 Provide training to staff members. Please specify: 3. Improve access and signage in your facilities/ environment  Carry out a review against the Dementia Friendly Environments √ checklist or similar www.dementiaaction.org.uk/assets/0000/4334/dementia_friendly_ environments_checklist.pdf  Provide alternatives where possible to people living with dementia e.g. Display a coin recognition chart, on the day appointment reminders. Please specify:  Other: Please specify: 4. Keep connected  Regularly visit www.dementiaaction.org.uk/dementiafriendly for √ more tips on becoming dementia friendly  Let other organisations know about the DAA so they can become √ part of their Local Alliance  Promote dementia friendly approaches through internal/external √ communications

Please add any local alternatives or additional activities you have completed or intend to undertake during 2014/2015 related to becoming Dementia Friendly:

If your Local Dementia Action Alliance has signed up to the Dementia Friendly Communities Recognition Process, you may be eligible to use the ‘Working to become Dementia Friendly Symbol (2014/2015)’ subject to approval.

To see which communities are working to become dementia-friendly visit : www.alzheimers.org.uk/recognitionprocess

Please return this form to:

Your Local Dementia Action Alliance Coordinator. Please click here to find their contact details or visit www.dementiaaction.org.uk/local_alliances

Alternatively, you can return this form to the DAA Secretariat: Email: [email protected] Post: DAA c/o Alzheimer’s Society, Devon House, 58 St Katharine's Way, London, E1W 1LB