National Family Caregivers Association

Friday Jul 30, 2010

Family Caregiver Sign Up

Become part of NFCA's Family Caregiver Community!

Sign up TODAY to access the latest resources, connect with others, and find support with NFCA's Family Caregiver Community…

Throughout the year, we offer members who sign up FREE resources including:

NFCA's quarterly e-newsletter, TAKE CARE! with information and resources about the experiences of caregiving. To receive a print version of the newsletter in the mail, please join at the special, $10 introductory rate.
An educational library with resources to support your day-to-day responsibilities
An online story bank with stories from caregivers across the country
A Pen Pal program that connects you directly with others who are caring for loved ones
Monthly E-letters created exclusively for family caregivers

Becoming part of NFCA's Family Caregiver Community is easy and free. Please sign up now. If you NOT currently a caregiver, but wish to receive NFCA's information please join us in one of the following categories:

Family, Friends, Former Caregivers
Professionals
Organizations

NOTE to CURRENT caregiver members who want to confirm their desire to receive the electronic version of the quarterly newsletter, Take Care!: DO NOT USE THIS FORM. Send an e-mail to newsletter@thefamilycaregiver.org with your name, street address, phone number, and – in the body of the message – the e-mail address at which you want to receive the newsletter.

If you are NOT already a member, you must use this form to join. Your free caregiver membership includes the e-mailed newsletter.

NFCA Family Caregiver Community

Yes! I want to sign up for FREE because I am a family caregiver

Personal Information

Name* (first and last):

Address 1*:

Address 2 (Apt. #, etc.):

City*:

State*:

ZIP Code*:

Telephone Number*:

E-Mail Address*:

How did you hear about the NFCA?

1. How many years have you been caring for your loved one?

  0-5 years
  6-10 years
  11+ years

2. What is your relation to the person for whom you're caring? I am the:

  Spouse
  Parent
  Sibling
  Child
   Other

3.What is your age?

  Under 11
  11-20
  21-35
  36-50
  51-65
  65+

4. What is the age of your loved one?

  Under 11
  11-20
  21-35
  36-50
  51-65
  65+

5. Where does your loved one live?

  With me
  Nursing home/assisted living facility
  On their own
  Other family member
   Other

6. What is the primary illness or disability of your loved one? CHECK ONE ONLY

  ALS
  Alzheimer's/Dementia
  Birth Defects/Related Conditions
  Cancer
  Cerebral Palsy
  Diabetes
  Frail/Elderly
  Heart Disease
  Age-Related Macular Degeneration
  Mental Illness
  Mental Retardation/Developmental Disorder
  Multiple Sclerosis
  Parkinson's Disease
  Pulmonary Disease
  Renal Disease
  Spinal Cord Injury
  Stroke
  Traumatic Brain Injury
   Other

Please enter the above letters and numbers in the box below:

Note: NFCA will keep all of your information confidential; it will not be shared with any third parties. View our privacy policy here.

National Family Caregivers Association
10400 Connecticut Avenue, Suite 500
Kensington, MD 20895-3944