Memory Care Café Registration

Name

Preferred Name/Nickname

Pronouns (if comfortable)

Date of Birth

Primary Language

Phone

Email (applicable)

This address will receive a confirmation email

Care Partner / Emergency Contact (If applicable)

Care Partner/Emergency ContactName

Relationship to Participant

Phone

Zip Code

This address will receive a confirmation email

Memory & Cognitive Support

1. Has the participant received a memory-related diagnosis? No Yes Unsure

2. Current stage of memory change (if known): Early Changes (Mild Memory Loss) Middle Changes (Moderate Memory Loss) Later Changes (Advanced Memory Loss) Prefer not to say

3. How does memory change usually show up? (check all that apply) Forgetting names or words Confusion about time or placequestions or stories Difficulty following conversations Changes in mood or personality

Physical & Emotional Well-Being

1. Any mobility considerations? Walks independently Uses cane/walker Uses wheelchair Needs assistance

2. Sensory needs: Hearing support Vision support Vision support

3. Emotional support needs (optional): Anxiety Depression Agitation Loneliness Grief or loss Generally calm

Personal Preferences & Comfort

1. Activities the participant enjoys: Music Singing Arts & Crafts Storytelling Gentle Movement Nature Spiritual or prayer time Conversation

2. Topics or experiences that bring joy or comfort:

3. Anything that tends to cause distress or discomfort?

Spiritual & Cultural Considerations (Optional)

1. Spiritual or cultural practices we should honor:

2. Would the participant enjoy spiritual reflection, prayer, or meditation? Yes No Sometimes

Group Participation

1. Has the participant attended a support group before?

Yes No

2. What do you hope this group will offer? ☐ Companionship ☐ Emotional support ☐ Mental stimulation ☐ Spiritual connection ☐ Caregiver support

Safety & Care Notes

1. Allergies or medical concerns we should be aware of?

2. Is there anything important for facilitators to know to ensure comfort and safety?

Consent

☐ I give permission for participation in this memory care support group.

Yes No

☐ I understand this group is supportive in nature and not a substitute for medical care.

Yes No

Signature

Date

Description

Memory Care Café Pilot

A warm, multigenerational gathering for individuals living with memory loss, caregivers, families, and friends — younger folks welcome.

🗓 5-Month Pilot Program
🗓 First & Third Fridays
🗓 Starting March 20, 2026
⏰ 11:00 AM – 2:00 PM
📍 East Bay Church of Religious Science

Connection • Creativity • Community Care
💜 Free | Registration details coming soon

Memory Care Café Registration

Description

Please Fix the Following