Caregiver University

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Caregiver University Application Form

2024 Dates:

February 6-16, 2024
May 14-24, 2024
August 13-23, 2024
November 5-15, 2024

* = 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

() -

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.