Familiar Ground Participant Form

Name *

Mobile Phone *

Email

I live &/or work within the City of Merri-bek *

Yes

No

Prefered Pronouns

How would you best describe your experience of dementia *

I am a person living with dementia

I care for a person living with dementia

I am a close relative of someone living with dementia

Please indicate your age bracket

This helps us ensure we have a good representation of participants

Optional: If you’re comfortable, which option best describes the current stage of dementia for you or your loved one?

This information allows us to ensure we have a range of experiences represented.

Early Stage

Middle Stage

Late Stage

Is there anything important you’d like us to know - about you, your background, or what support you might need?

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