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Schmieding Center - Springdale
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Individual and Family Support Services
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Family Caregiver Workshop
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Schmieding Center - Springdale
Family Caregiver Workshop
Family Caregiver Workshop
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Birthday
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Enter required information below.
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First
Last
Email
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Phone
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Residence County
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Benton
Washington
Madison
Baxter
Boone
Carroll
Izard
Marion
Newton
Searcy
Stone
other
Gender
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Male
Female
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Race
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African-American
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Hispanic
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Profession
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Public/Community
Dietician
Medical Student
Nursing
Nursing Home Administration
Paraprofessional
Patient
Physical Therapy
Physician
Resident
Social Work
Student
How did you learn of this program?
(check all that apply)
Facebook
Website
Word of Mouth
My Center on Aging (the Schmieding Center)
My Healthcare Provider (e.g., doctor, nurse, etc.)
Other
Choose all sessions that you will attend
(Note the delivery method for the chosen session, In-Person or Zoom)
Middle Stage-Sep 26, 2024 from 1pm to 4pm (In-person ONLY)
Late Stage-Nov 19, 2024 from 9am to 12pm (In-person ONLY)
Early Stage-Dec 12, 2024 from 9am to 12pm (Zoom ONLY)
Middle Stage-Jan 8, 2025 from 9am to 12pm (Zoom ONLY)
Late Stage-Mar 13, 2025 from 9am to 12pm (Zoom ONLY)
Early Stage-April 10, 2025 from 9am to 12pm (In-person ONLY)
Middle Stage-April 29, 2025 from 1pm to 4pm (In-person ONLY)
Late Stage-June 12, 2025 from 9am to 12pm (In-person ONLY)
CONSENT TO USE MEDIA IMAGES FOR PROMOTIONS
I hereby give the University of Arkansas for Medical Sciences, their legal representative, assigns, and those acting on their behalf and with their permission, the right and permission to copyright in any part of the world, to use, reuse, publish and republish, in conjunction with my own or fictitious name, any photograph, film or video tape recording taken of me by the University of Arkansas for Medical Sciences or those acting on their behalf or with their permission, and any reproductions thereof, in any form, whether intentional or otherwise, and may be used in conjunction with any advertising material, for any purposes of trade, advertising, exhibit, publicity, or promotion, without restriction or limitations. I understand that the photographs, film and/or video may be used in news releases, newspapers or magazine articles, television, the UAMS website or social media sites (e.g., Facebook , YouTube). I hereby release, discharge, and agree to save harmless the University of Arkansas for Medical Sciences, their assigns, legal representatives, agents, and those acting on their behalf and with their permission, from and against any liability resulting from any distortion, blurring, alteration or use in composite form, whether such was intentional or otherwise, which my occur, result, or be produced in the taking of said photography, or by processing or reproduction of the finished product, its publication or the distribution of same. I waive the right to approve or inspect the recordings, advertising copy, or material used in conjunction therewith.
I consent, per above terms, to the use of my image by UAMS for program and event promotion
*
Required
Yes
No
I want to receive email notice about other Schmieding Center events
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Required
Yes
No
Survey data is required by our funder to offer this program at no cost to participants. Only aggregate (group) data from this survey is reported.
My knowledge about caregiving is
Excellent
Good
Fair
Poor
SCSHE
My understanding of dementia is
Excellent
Good
Fair
Poor
SCSHE
My confidence in being a caregiver is
Excellent
Good
Fair
Poor
SCSHE
My understanding of where to find help and resources is
Excellent
Good
Fair
Poor
SCSHE
My overall health is
Excellent
Good
Fair
Poor
SCSHE
My knowledge of how to care for the physical needs of my care recipient is
Excellent
Good
Fair
Poor
SCSHE
My confidence in taking charge of my care recipient's health is
Excellent
Good
Fair
Poor
SCSHE
Δ