Registration Form for Music, Movement & Community Program

MMC is an in-person and virtual interactive experience where music and expression ignite joy. This is in an inclusive and stimulating learning environment of personal connection and fun. Our sessions are led by a Chicago based musician and educator - designed for families walking with younger-onset dementia. Younger-onset is defined as those diagnosed under 65 years old. There is no cost for this program.

The MMC program is hosted regularly Old Town School of Folk Music at 4544 North Lincoln Avenue, Chicago, Illinois and held the 2nd and 4th Saturdays of the month with periodic breaks throughout the year. The classes begin at 11:00 am and conclude by 12:30 pm.

The 4th Saturday of the month is our hybrid program--virtually via zoom and in-person at Old Town. If you live outside the Chicagoland area and will only be able to participate virtually, please select this option.

We have scheduled in-person community MMC experiences this spring including the following:

April 18: 11:30A-12:30P Kroc Center Memory Cafe-1250 W 119th Street

May 8: 1-2P South Loop Memory Cafe-Second Presbyterian Church 1936 S Michigan Avenue

June (date + time TBD) Englewood Memory cafe

Program is funded by Northwestern University and the Foundation for Health Enhancement.

Please select from the options below. You may choose more than one.*

Old Town School of Folk Music, 4544 North Lincoln Avenue, Chicago (you may also join virtually if that is more convenient)

Virtual Class ONLY

In-Person Community @ Memory Cafe

Please provide us with the following basic information so that we can reserve space for you and your family in this program.

First name*

Last name*

Email*

City

State/Region

Phone number*

If you agree to receive text, please check this box

Opt-In Text (messages/reminders)

I am*

Please share your relationship to dementia.

A person walking w/ younger-onset dementia

A child (under 18) of a person w/ younger-onset dementia

A child (18+) of a person w/ younger-onset dementia

A carepartner, carer or caregiver of a person w/ younger-onset dementia

A dementia expert

A supporter

Other

What is the birth year of the participant?*

If known, what year was the participant diagnosed?

Race/Ethnicity (optional)

Race/Ethnicity Other

How many people in your family plan to attend?*

Please provide information regarding who will be participating in the Music, Movement & Community program.*

Please review and accept the following:

Code of Conduct - Please read here and accept.*

Thank you so much for submitting your reservation.