Author: Kathleen Kenney
Last saved by: kenneyk3@gmail.com
Company: webdunia

Caregiver Support Group (continued)

"Focus"

Caregiver Support Group 
   Registration Form
 
    - Getting to Know You - 

		We are so happy to welcome you to our Caregiver Support Group!  Filling 			out this form, and telling us a bit about yourself, will help us to better 				organize meeting agendas.

		Please type directly on the form and return to: 				 				Lisa.DiBonaventura@mass.gov                              Thank you so much!
	
	Today’s Date:   
	Name:  
	Email Address:
	Phone: 
	Agency Name and Address:
	DDS Region (Central-West, Metro, Northeast or Southeast):
	Primary Language:
	Location of Service:  Please check all that apply:
•	Home
•	Day Program
•	Work
•	Transportation
•	Other/Please Describe:
	Which reoccurring Caregiver Support Group would you like to sign up for?	
•	2^nd Tuesday of each Month from 10:00am to 11:00am
•	2^nd Wednesday of each Month from 4:00pm to 5:00pm
•	Both Caregiver Support Groups (each month I’ll decide which best fits into my schedule)

Availability of Technology:  Please check all that are available for use:
•	Landline phone
•	Cellphone
•	iPad
•	Laptop
•	Desktop Computer

Number of individuals with Vision Impairment, Legal Blindness or Deaf Blindness with whom you work: 

Please tell us about yourself and your expectations for this Caregiver Support Group:

If you would like to request an ADA or religious accommodation, please indicate here: 

Next Steps: 
•	Please return completed form to: 	Lisa.DiBonaventura@mass.gov    
•	A link for the Caregiver Support Group meeting(s) will be emailed to you.
                          
Questions? 
Please don’t hesitate to contact:   Lisa.DiBonaventura@mass.gov

Thank You!

Please note:  These Web links are being offered only as informational resources. 
                                  It is not our intention to endorse or recommend the sites.
			
A resource of the MCB/DDS Partnership Project
          
focusonvisionandvisionloss.org                         
508.384.5539

"Focus"

Page

Please note:  These Web links are being offered only as informational resources. 
                                   It is not our intention to endorse or recommend the sites.

A resource of the MCB/DDS Partnership Project
          
focusonvisionandvisionloss.org                         
508.384.5539

"Focus"