Alzheimer's Association - Greater Illinois Chapter

Support Group Listing Update Request

This form is for current support group facilitators who are requesting to change information about their group, e.g. the time the group meets and / or the facilitator’s contact information.



	Town Name:
	Location: (ie: church)
	Address:
	City:
	State:
	County:
	Zip Code:
	Name:
	Work Phone: (to confirm listing)
	Other Phone: (to give out to public)
	Email:
	Day of Group: (ie: 1st Mondays)
	Frequency of Group:
	Time of Group:
	Type of Group: (ie: adult children or spouses only. Please leave blank if group is general)
	Update Request: (ie: holiday schedule, canceled group, etc.)
	For verification purposes, please enter the numbers you see below: *~~158716572~~*