Apna Mind, Apna Body – Dementia Activity Kit Order Form

Name *

First

Last

Email *

Phone

Who is requesting the kit?

Have you or your loved ones been formally diagnosed with dementia? *

Do you see a healthcare provider for your dementia care? *

How are you and your loved ones affected by Dementia? *

Your age or the age of the individuals diagnosed with Dementia? *

What's your gender? *

What's your ethnic background? *

Which Dementia Activity Kit would you prefer?

Option one- The Joy for all pet, Jigsaw puzzle, Colouring Book, Markers, Easy Brain Activity Book, Fidget Cube, Aqua Paint
Option Two: Jigsaw Puzzle, Colouring Book, Marker, Easy Brain Activity Book, Fidget Cube, Aqua Paint

How do you wish to receive the Dementia kit?

Complete Mailing Address (Ontario Residents Only) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Pick up Activity Kit (weekday only) - Please do not pick up your activity kit until you receive a confirmation email. *

After 6 weeks of receiving your Dementia Activity Kit we will be emailing you a feedback survey on the items received.

905-366-1010