APPENDIX  4

REGISTRATION FORM FOR CAREGIVER EDUCATION AND SUPPORT WORKSHOPS

I would like to register for the Caregiver Education and Support Workshops being held on [DATE] at [LOCATION].

Date of registration: _________________________

Name: _____________________________________________________________  Address:____________________________________________________________
___________________________________________________________________
Contact number:______________________________

Are you currently providing care for a family member or friend?   ___________________________________________________________________

Do you live with the person you are caring for?___________________________________

Can you briefly describe your caregiving situation? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
	
How did you hear of the Caregiver Education and Support Workshops? ___________________________________________________________________ 

What would you like to gain from the workshops? ______________________________________________________________________________________________________________________________________ 
 
Special Needs: ________________________________________________________

(Optional)
Age: __________________ Martial status: _____________