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I'll Be There!
Memory Cafe
First and Third Wednesdays at 4:00 pm

First Name*

Email Address*

Last Name*

Cell Phone

Demographic Information
Thank you for providing answers to the questions below.
Answers are kept anonymous and help us complete our grant reporting to keep these programs free!
If you have completed this since July 2020, you may skip this form and submit your registration.

Today's Date

I am a Fairfax County resident.

Yes No

I am a single mother with dependent children.

Yes No

I have a child under the age of 18 living in the house.

Yes No

There is an individual who has an impairment that limits one or more major activities living in my home.

Yes No

There is an adult over 55 living in my home.

Yes No

There is someone living with me who desires employment, but is not currently employed. (Do not include a dependent in high school or below.)

Yes No

I am enrolled in TANF.

Yes No

Race

Household Size

Annual Household Income

How did you hear about the program?

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Thanks for your registration!
Thank you for your RSVP. We look forward to seeing you soon!

Here is the link to join the memory cafe from your computer, tablet or smartphone.
This link will also be emailed to the address you provided.
https://www.gotomeet.me/INSIGHTMEMORYCARECENTER/memory-cafe

You can also dial in using your phone.
United States: +1 (646) 749-3122
Access Code: 612-689-109

If you have any questions before the group, please don't hesitate to contact us!

Katelyn Sloan, Marketing Director
katelyn.sloan@insightmcc.org
703-204-4664

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