I am a person with dementia and this is my story.

By submitting your story, you agree that the Alzheimer’s Association may use your statements for educational or advocacy purposes in print or electronic format. The content of your story will not be changed, however, excerpts may be used. To protect your privacy, only your first name will be referenced.

The following questions are available to guide you:

• How has your life changed since your diagnosis?
• What experiences have been the most challenging for you?
• How do you cope with your illness? Where do you find support?
• What needs to be done to ease the challenges of living with dementia?

Enter your story below:

Legislators and donors want to know more about how we help you though our programs and services. Please answer the following questions, so that we can continue to offer assistance to you and others in the community.

	1.	What Alzheimer’s Association services do you or your family use?
			Support Groups 24/7 Helpline Care Consulation Education & Training Programs	Safe Return Internet Resources Other:
	2.	How has the Alzheimer’s Association supported you?

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Contact Information (optional)

Name:
Address:
City:
State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:
Phone:	example 123-456-7890
E-Mail:
Confirmation Format	HTML  Plain Text This is an e-mail you will receive when this form is filled out. Choose the format that works best with your e-mail. Help

We would like to share your story with the legislator who represents you. For this purpose, please provide at least your zip code.