Submitted by sagewebadmin on Thu, 06/11/2015 - 14:18 When you connect to Caregiver Action Network for free you can: Connect anonymously with other family caregivers in the Care Community to receive encouragement and advice Read caregiver’s stories or share your story to help others Receive our monthly e-newsletter TakeCare! for caregiving news and tips Feel safe and secure knowing that your information is completely safe with us. We will NEVER share, sell, rent or in any way release your personally identifiable information to any third party for any reason. Engage with us on Facebook and Twitter Connect Now! It’s simple. Complete the form below knowing that your information is completely safe. CAN may use the answers you and others provide in the aggregate to understand your needs and provide you with better service. First Name * Last Name * Email * Username for Care Community * Address * Address Line 2 City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Country * AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Please answer some questions so that we may assist you better Ok Who are you caring for? - None -Spouse/PartnerParentGrandparentChild with Special NeedsSibling Where does your loved one live? - None -With me in my homeWith me in their homeOn their own nearby (within 25 miles)On their own far away (more than 25 miles away)In a facility (assisted living, nursing home, etc.) How many years have you been caring for your loved one? - None -0-23-56-1011+ What is the primary illness, disability, or condition of your loved one? - None -Accident or TraumaALS/Lou Gehrig's diseaseAlzheimer's disease and/or dementiaAutismBirth Defects/related conditionsCancerCerebral PalsyChronic PainDevelopmental DisorderDiabetesHearing impaired/DeafHeart diseaseMental IllnessMultiple SclerosisOld AgeParkinson's diseasePhysical DisabilityPTSDPulmonary disease and/or COPDRenal diseaseSpinal Cord InjuryStrokeTraumatic Brain Injury (TBI)Vision problems including AMDOther If you answered "Other" to the previous question, please provide a short description What is your age? - None -Under 2121-3536-5051-6465+ What is the age of your loved one? - None -Under 2121-3536-5051-6465+ Leave this field blank CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 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