Current Results for 2017 Georgia Awareness Day Registration Form

1. Please provide the following--we need your address in order to look up who your state senator and representative are; we need your phone number in case we need to call you back to the church if you are at the Capitol and your legislator joins us there:

Total Number of Responses

245

2. Please check all of the following that apply:

Total Number of Responses 245

Value

 

Count

 

Percent

I am a family member of a person with dementia

 

98

 

40.0

Other

 

88

 

35.9

I am a family caregiver for a person with dementia

 

65

 

26.5

I am a friend of a person with dementia

 

52

 

21.2

I am a professional care provider for a person with dementia

 

23

 

9.4

I am a medical professional serving a person with dementia

 

16

 

6.5

I am a researcher

 

8

 

3.3

User Provided No Response

 

4

 

1.6

I am a person with Alzheimer's disease or a related dementia

 

3

 

1.2

I have early stage Alzheimer's disease

 

3

 

1.2

I have younger-onset Alzheimer's disease

 

2

 

0.8

  

3. If I am a person with Alzheimer's or a related dementia, my date of diagnosis was:

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #3

4. I plan to attend the FEBRUARY 3, 2017, Alzheimer's Awareness Day at the Georgia State Capitol, 8:30 a.m. - 3:00 p.m.

Value

 

Count

 

Percent

Yes

 

240

 

98.0

No

 

5

 

2.0

  

5. Please indicate your interest in the training below:

Value

 

Count

 

Percent

Atlanta Chapter Office, Thursday, January 26, 10:00am-12:00pm | 41 Perimeter Center East; Ste. 550; Atlanta, GA 30346

 

70

 

28.6

Atlanta Chapter Office, Monday, January 23, 6:30pm-8:30pm | 41 Perimeter Center East; Ste. 550; Atlanta, GA 30346

 

55

 

22.4

Dalton Service Area, Tuesday, January 17, 5:30pm-7:30pm | 922 East Morris Street, Dalton, GA 30721

 

19

 

7.8

Tifton Service Area, Tuesday, January 31, 5:00pm-7:00pm | 225 2nd Street East, Tifton, GA 31794

 

15

 

6.1

Augusta Service Area, Friday, January 27, 10:00am-12:00pm | 106 SRP Drive, Evans, GA 30809

 

13

 

5.3

Augusta Service Area, Friday, January 20, 2:00pm-4:00pm | 106 SRP Drive, Evans, GA 30809

 

12

 

4.9

Macon-The Farm House, Wednesday, January 18, 5:00pm-6:30pm | 95 Chantilly Drive, (behind McCullough Funeral Home), Warner Robins, GA 31088

 

12

 

4.9

Columbus Service Area, Wednesday, January 18, 6:00pm-7:30pm | 5156 River Road, Suite M, Columbus, GA 31904

 

8

 

3.3

Savannah Service Area, Tuesday, January 24, 10:30am-12:00pm | 201 Television Circle, Savannah, GA 31406

 

8

 

3.3

Macon Service Area, Wednesday, January 18, 9:30am-10:30am | 886 Mulberry Street, Macon, GA 31201

 

8

 

3.3

Dalton-Area Agency on Aging, Tuesday, January 10, 3:00pm5:00pm | 1 Jackson Hill Drive, Conference Room, Rome, GA 30161

 

6

 

2.4

Columbus Service Area, Wednesday, January 11, 10:00am-11:30am | 5156 River Road, Suite M, Columbus, GA 31904

 

5

 

2.0

Tifton Service Area, Tuesday, January 17, 10:00am-12:00pm | 225 2nd Street East, Tifton, GA 31794

 

4

 

1.6

Columbus-Vernon Woods, Tuesday, January 17, 6:00pm-7:30pm | 101 Vernon Woods Drive, LaGrange, GA 30240

 

3

 

1.2

Columbus Service Area, Thursday, January 19, 12:00pm-1:30pm | 5156 River Road, Suite M, Columbus, GA 31904

 

3

 

1.2

Atlanta Chapter Office, Thursday, January 26, 10:00am-12:00pm

 

1

 

0.4

Columbus-Spalding County Senior Center, Wednesday, January 18, 10:00am-11:30am | 885 Memorial Drive, Griffin, GA 30223

 

1

 

0.4

Savannah-Location TBD, Thursday, January 26, 1:00pm-3:00pm | Brunswick Location TBD

 

1

 

0.4

Columbus Service Area, Thursday, January 12, 12:00pm-1:30pm | 5156 River Road, Suite M, Columbus, GA 31904

 

1

 

0.4

  

6. We are providing a newly-designed t-shirt for Awareness Day this year. We ask that all attendees wear their T-shirt on Awareness Day. In order to have your t-shirt available for you to pick up when you attend an Awareness Day Training in your Chapter Service area, please provide us your preferred t-shirt size.

Value

 

Count

 

Percent

Large

 

75

 

30.6

Medium

 

62

 

25.3

XL

 

60

 

24.5

Small

 

22

 

9.0

2X

 

20

 

8.2

3X

 

5

 

2.0

I already have a t-shirt--do not order one for me

 

1

 

0.4

  

7. First Name of additional attendee #1

Latest User Responses:

User Provided No Response
 

 

 

Sonya Johnson Clark
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #7

8. Last Name of additional attendee #1

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #8

9. Street Address of additional attendee #1

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #9

10. City/State/Zip of additional attendee #1

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #10

11. Email address of additional attendee #1

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #11

12. Phone of additional attendee #1

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #12

13. Emergency Contact Number for additional attendee #1

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #13

14. Please check all of the following that apply for Additional Attendee #1:

Total Number of Responses 245

Value

 

Count

 

Percent

User Provided No Response

 

195

 

79.6

I am a family member of a person with dementia

 

22

 

9.0

I am a family caregiver for a person with dementia

 

14

 

5.7

I am a friend of a person with dementia

 

7

 

2.9

Other

 

7

 

2.9

I am a professional care provider for a person with dementia

 

5

 

2.0

I am a medical professional serving a person with dementia

 

4

 

1.6

I am a person with Alzheimer's disease or a related dementia

 

4

 

1.6

I have younger-onset Alzheimer's disease

 

1

 

0.4

I am a researcher

 

1

 

0.4

I have early stage Alzheimer's disease

 

1

 

0.4

  

15. [Additional Attendee #1]I plan to attend the Friday, February 3, Alzheimer's Awareness Day at the Georgia State Capitol, 8:30 a.m. - 3:00 p.m. (Training location addresses will be listed in the confirmation email you will receive after registering).

Value

 

Count

 

Percent

User Provided No Response

 

203

 

82.9

Yes

 

39

 

15.9

No

 

3

 

1.2

  

16. [Additional Attendee #1] Please indicate your interest in the training below:

Value

 

Count

 

Percent

User Provided No Response

 

203

 

82.9

Atlanta Chapter Office, Monday, January 23, 6:30pm-8:30pm | 41 Perimeter Center East; Ste. 550; Atlanta, GA 30346

 

10

 

4.1

Atlanta Chapter Office, Thursday, January 26, 10:00am-12:00pm | 41 Perimeter Center East; Ste. 550; Atlanta, GA 30346

 

8

 

3.3

Tifton Service Area, Tuesday, January 31, 5:00pm-7:00pm | 225 2nd Street East, Tifton, GA 31794

 

4

 

1.6

Macon-The Farm House, Wednesday, January 18, 5:00pm-6:30pm | 95 Chantilly Drive, (behind McCullough Funeral Home), Warner Robins, GA 31088

 

4

 

1.6

Columbus Service Area, Wednesday, January 18, 6:00pm-7:30pm | 5156 River Road, Suite M, Columbus, GA 31904

 

3

 

1.2

Dalton-Area Agency on Aging, Tuesday, January 10, 3:00pm5:00pm | 1 Jackson Hill Drive, Conference Room, Rome, GA 30161

 

3

 

1.2

Dalton Service Area, Tuesday, January 17, 5:30pm-7:30pm | 922 East Morris Street, Dalton, GA 30721

 

3

 

1.2

Augusta Service Area, Friday, January 20, 2:00pm-4:00pm | 106 SRP Drive, Evans, GA 30809

 

2

 

0.8

Savannah Service Area, Tuesday, January 24, 10:30am-12:00pm | 201 Television Circle, Savannah, GA 31406

 

1

 

0.4

Columbus-Vernon Woods, Tuesday, January 17, 6:00pm-7:30pm | 101 Vernon Woods Drive, LaGrange, GA 30240

 

1

 

0.4

Savannah-Location TBD, Thursday, January 26, 1:00pm-3:00pm | Brunswick Location TBD

 

1

 

0.4

Augusta Service Area, Friday, January 27, 10:00am-12:00pm | 106 SRP Drive, Evans, GA 30809

 

1

 

0.4

Macon Service Area, Wednesday, January 18, 9:30am-10:30am | 886 Mulberry Street, Macon, GA 31201

 

1

 

0.4

  

17. [Additional Attendee #1] We are providing a newly-designed t-shirt for Awareness Day this year. We ask that all attendees wear their T-shirt on Awareness Day. In order to have your t-shirt available for you to pick up when you attend an Awareness Day Training in your Chapter Service area, please provide us your preferred t-shirt size.

Value

 

Count

 

Percent

User Provided No Response

 

196

 

80.0

Large

 

14

 

5.7

XL

 

12

 

4.9

Medium

 

11

 

4.5

2X

 

8

 

3.3

Small

 

3

 

1.2

3X

 

1

 

0.4

  

18. First Name of additional attendee #2

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #18

19. Last Name of additional attendee #2

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #19

20. Street Address of additional attendee #2

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #20

21. City/State/Zip of additional attendee #2

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #21

22. Email address of additional attendee #2

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #22

23. Phone of additional attendee #2

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #23

24. Emergency Contact Number for additional attendee #2

Latest User Responses:

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 

User Provided No Response
 

 

 


View All Responses for question #24

25. Please check all of the following that apply for Additional Attendee #2:

Total Number of Responses 245

Value

 

Count

 

Percent

User Provided No Response

 

229

 

93.5

I am a family member of a person with dementia

 

4

 

1.6

I am a professional care provider for a person with dementia

 

4

 

1.6

I am a friend of a person with dementia

 

2

 

0.8

I am a person with Alzheimer's disease or a related dementia

 

2

 

0.8

I have early stage Alzheimer's disease

 

2

 

0.8

I am a medical professional serving a person with dementia

 

1

 

0.4

Other

 

1

 

0.4

  

26. [Additional Attendee #2] I plan to attend the Friday, February 3, Alzheimer's Awareness Day at the Georgia State Capitol, 8:30 a.m. - 3:00 p.m. (Training location addresses will be listed in the confirmation email you will receive after registering).

Value

 

Count

 

Percent

User Provided No Response

 

230

 

93.9

Yes

 

15

 

6.1

  

27. [Additional Attendee #2] Please indicate your interest in the training below:

Value

 

Count

 

Percent

User Provided No Response

 

229

 

93.5

Atlanta Chapter Office, Thursday, January 26, 10:00am-12:00pm | 41 Perimeter Center East; Ste. 550; Atlanta, GA 30346

 

3

 

1.2

Atlanta Chapter Office, Monday, January 23, 6:30pm-8:30pm | 41 Perimeter Center East; Ste. 550; Atlanta, GA 30346

 

3

 

1.2

Augusta Service Area, Friday, January 20, 2:00pm-4:00pm | 106 SRP Drive, Evans, GA 30809

 

3

 

1.2

Macon-The Farm House, Wednesday, January 18, 5:00pm-6:30pm | 95 Chantilly Drive, (behind McCullough Funeral Home), Warner Robins, GA 31088

 

2

 

0.8

Dalton Service Area, Tuesday, January 17, 5:30pm-7:30pm | 922 East Morris Street, Dalton, GA 30721

 

1

 

0.4

Columbus Service Area, Wednesday, January 18, 6:00pm-7:30pm | 5156 River Road, Suite M, Columbus, GA 31904

 

1

 

0.4

Dalton-Area Agency on Aging, Tuesday, January 10, 3:00pm5:00pm | 1 Jackson Hill Drive, Conference Room, Rome, GA 30161

 

1

 

0.4

Savannah-Pittman Park UMC, Wednesday, January 25, 10:30am-12:00pm | 1102 Fair Rd, Statesboro, GA 30458

 

1

 

0.4

Columbus Service Area, Thursday, January 12, 12:00pm-1:30pm | 5156 River Road, Suite M, Columbus, GA 31904

 

1

 

0.4

  

28. [Additional Attendee #2] We are providing a newly-designed t-shirt for Awareness Day this year. We ask that all attendees wear their T-shirt on Awareness Day. In order to have your t-shirt available for you to pick up when you attend an Awareness Day Training in your Chapter Service area, please provide us your preferred t-shirt size.

Value

 

Count

 

Percent

User Provided No Response

 

231

 

94.3

XL

 

6

 

2.4

Medium

 

3

 

1.2

Large

 

3

 

1.2

2X

 

2

 

0.8