<p> Virginia Caregiver Coalition</p><p>Please complete the following information to keep on file as we network, grow, and find our strengths.</p><p>9:30 A.M. – NOON at Charlottesville Health Department 2010 July 15; September 16; November 18; 2011 January 20; March 17, May 19</p><p>Scheduler Annie Marrs, [email protected] or 434-973-6122 Alzheimer's Association, Central & Western VA</p><p>Type of Membership (check one) Organization:___ or Individual: ___</p><p>Name of agency (if applicable): </p><p>Website: ______</p><p>Your name: </p><p>Professional title: ______</p><p>Family Caregiver: _____Yes _____No Contact information Address </p><p>Phone Number </p><p>E-mail address </p><p>In your view, and the view of your agency, what issues face the family caregiver today?</p><p>What services does your organization provide to help the family caregiver?</p><p>What strengths do you bring as an individual?</p><p>What would you like to see the coalition focus on in the next year?</p><p>In the long-term? </p><p>What organizations, skills, or talents do you think need to be included in the coalition?</p><p>Should I be invited to join the Virginia Caregiver Coalition, I will meet the following expectations:</p><p> 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.</p><p>Printed Name: ______</p><p>Signature: ______</p><p>Date: ______</p><p>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</p>