Caregiver Support Group 
   Registration Form
 
    - Getting to Know You - 

		We are so happy to welcome you to our Caregiver Support Group!  Filling 			out this form, and telling us a bit about yourself, will help us to better 				organize meeting agendas.

		Please type directly on the form and return to: 				 				Lisa.DiBonaventura@mass.gov                              Thank you so much!
	
	Today’s Date:   
	Name:  
	Email Address:
	Phone: 
	Agency Name and Address:
	DDS Region (Central-West, Metro, Northeast or Southeast):
	Primary Language:
	Location of Service:  Please check all that apply:
•	Home
•	Day Program
•	Work
•	Transportation
•	Other/Please Describe:
	Which reoccurring Caregiver Support Group would you like to sign up for?	
•	2nd Tuesday of each Month from 10:30am to 11:30am
•	2nd Wednesday of each Month from 4:30pm to 5:30pm
•	Both Caregiver Support Groups (each month I’ll decide which best fits into my schedule)

Availability of Technology:  Please check all that are available for use:
•	Landline phone
•	Cellphone
•	iPad
•	Laptop
•	Desktop Computer

Number of individuals with Vision Impairment, Legal Blindness or Deaf Blindness with whom you work: 

Please tell us about yourself and your expectations for this Caregiver Support Group:

Next Steps: 
•	Please return completed form to: 	Lisa.DiBonaventura@mass.gov    
•	A link for the Caregiver Support Group meeting(s) will be emailed to you.
                          
Questions? 
Please don’t hesitate to contact:   Lisa.DiBonaventura@mass.gov

Thank You!