Caregiver Action Network Webinar Confirmation

Thanks for registering for our upcoming webinar.

Your registration has been received, and we’re so glad you’ll be joining us.

In the next 10 minutes, you’ll receive an email from Zoom with your confirmation and calendar invitation.

Before you go, take a moment to complete our quick survey below.

By sharing your insights, you’ll help the Caregiver Action Network and our partners improve resources for caregivers like you nationwide.

"*" indicates required fields

Your Details

Your Name*

Your Email Address*

Phone*

Your Gender*

Your Age*

Your Address*

Preferred Language*

Sexual Orientation*

What racial or ethnic group do you most closely identify with? (Select all that apply)*

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White/Non-Hispanic Latino

Hispanic or Latino

Middle Eastern

What is your approximate household income?*

Sharing information like this helps CAN tailor programming and resources to the needs of our members, while recognizing the unique financial burden caregiving can place on a household.

Caregiving Information

Are you currently caring for more than one individual?*

Please complete the remainder of the form based on the individual who requires the most care or for whom you provide the most support.

Would you be interested in participating in a focus caregiver roundtable to share your insights and story?*

Your Caregiver Status*

Your Relationship to Your Care Recipient*

Your Care Recipient's Gender*

Your Care Recipient's Age*

Where Does Your Care Recipient Live*

How Long Have You Been Providing Care*

Do you or your Care Recipient identify as part of a historically underserved or marginalized community?*

How would you define your location?*

What is your Care Recipient's primary illness, disability or condition?*

Please specify condition:*

What are the primary challenges you face as a caregiver?*

Managing Daily Activities (e.g., bathing, dressing)

Behavioral or Psychological Symptoms (e.g., agitation, confusion)

Communication Difficulties

Medical or Health Management

Financial or Legal Concerns

Emotional or Mental Health Strain

Accessing Support Services

Other

Lend Your Voice: Caregiver Insights Panel

It is important to CAN’s work and mission to highlight caregivers sharing their caregiving experiences via video. CAN staff will work with caregivers indicating an interest in making a video testimonial.

Would you be willing to record a video testimonial?*

Would you need the support of CAN staff to record a video testimonial or are you comfortable submitting a self-recorded video testimonial (captured via your phone, laptop, or other device?*

Please select the general themes or topics that are relevant to your caregiving and what you would want to highlight or speak to in a video testimonial:*

The importance of self-care to you as a caregiver

The unique challenges or components of your caregiving connected to your loved one’s condition or diagnosis (e.g., frequent hospitalizations or E.R. visits, complex medical care needed at home, etc.)

Navigating insurance and health systems

Navigating medical care (e.g., communicating with doctors and specialists)

Complex relationship dynamics

Work and caregiving

Below are a set of questions or prompts that we have found generally impactful to include in this type of storytelling. Check any of the questions/prompts you feel comfortable responding to in a video testimonial.*

Who do you care for?

What's something people don't understand about caregiving?

This year's National Family Caregivers Month theme is "Care Connects Us." How has caregiving connected you to other people, communities, or sources of support?

What keeps you going on the hard days?

What would you tell another caregiver supporting a loved one with a similar condition or diagnosis to your loved one?

What gives you hope about the future of caregiving?

Media Release*

I give Caregiver Action Network permission to use my likeness and information shared on behalf of my participation with this Roundtable for purposes of promotion. This is includes information provide by this survey and other intake forms and recorded captures from the Roundtable itself.

I understand that Caregiver Action Network will not provide my information to outside entities without my additional expressed consent.

I agree

I do not agree

CAPTCHA

The Latest

partner sites

Conditions

Alzheimer’s

Heart Failure

Mental Health

Parkinson’s

Rare Disease

Schizophrenia

Sickle Cell

Stroke

TBI

More>

Toolbox

Information

Support

Agencies & Organizations

Community

Respite Care

Peer-to-Peer Support

Emotional Support

Clinical Trial Support

CAN Initiatives

About CAN

Who We Are

Leadership

Innovation Council

Celebrity Champions

Corporate Partners

Public Policy

Caregiver-Ready Workplaces

Caregiving Landscape

Lend Your Voice

Stay Connected

The Latest

partner sites

Conditions

Alzheimer’s

Heart Failure

Mental Health

Parkinson’s

Rare Disease

Schizophrenia

Sickle Cell

Stroke

TBI

More>

Toolbox

Information

Support

Agencies & Organizations

Community

Respite Care

Peer-to-Peer Support

Emotional Support

Clinical Trial Support

CAN Initiatives

About CAN

Who We Are

Leadership

Innovation Council

Celebrity Champions

Corporate Partners

Public Policy

Caregiver-Ready Workplaces

Caregiving Landscape

Lend Your Voice

Stay Connected

The Latest

partner sites

Conditions

Alzheimer’s

Heart Failure

Mental Health

Parkinson’s

Rare Disease

Schizophrenia

Sickle Cell

Stroke

TBI