Application Form - Dementia Friendly America

DFA Community Application

Ready to join the growing network of Dementia Friendly Communities?

Please complete this application form and attach:

Three or more letters of support representing different community sectors
If your DFA community is in a state with a DFA state lead, please include an additional letter of support from that agency/ individual.

Consult the Readiness and Recognition Criteria to ensure you are being thorough.

Contact information for person submitting this form:(Required)

First Name Last Name

Your Title(Required)

Agency/ Organization(Required)

Your Email Address(Required)

Enter Email Confirm Email

Your Phone(Required)

Dementia Friendly Location(Required)

City State

Does your state have a DFA State lead?

If yes, please list them here:

Click the plus sign to add more.

DFA communities convene a cross-sector team across three or more community sectors to advance dementia friendliness. A cross-sector team includes at a minimum, government, clinical, community-based organizations and at least one person living with dementia and their care partner from the community. Please summarize.

Who will be involved in the cross-sector team (Please list the individuals/ agencies: names, title, organization)?(Required)

Note: A DFA Community action team should include a person living with dementia and a care partner.

How will your community establish these connections across sectors?(Required)

How will your community engage people living with dementia and care partners?(Required)

Please list what community sectors your dementia friendly community initiative will focus on. DFA communities must convene across three or more community sectors.(Required)

The following are all of the DFA community sectors, but please add others if they are not listed. Airports, Banks and Financial Services, Neighbors and Community Members, Legal and Advance Planning Services, Local Government, Healthcare Throughout the Continuum, Libraries, Faith Communities, Businesses, Community-based Services and Supports, Residential and Specialty Care, Hospitals, Entertainment, Personal Services, Travel, and First Responders.

A Champion organization is one that is willing to champion, coordinate and, if needed, serve as a fiscal sponsor for the initiative. The champion organization may also help recruit and partner with a senior leader of local government in the effort. Has your initiative identified a Champion organization?(Required)

Please provide the name of the organization and brief description.

Please outline how you are (or plan to) assess your community’s strengths and weaknesses to develop an action plan:(Required)

It is expected that DFA communities use the Evaluation Guide to evaluate at least one component of your work. Please provide an overview of how you plan to evaluate your dementia friendly efforts.(Required)

DFA communities report progress by providing a current program description and by completing periodic surveys. Please confirm your commitment to participating:(Required)

Please describe how you plan to sustain any new initiatives undertaken as a DFA community.(Required)

Please compose a one-paragraph project description to be used for public dissemination.(Required)

Please touch on specific initiatives your community is implementing, sectors you are engaging and future plans.

Is your organization an Area Agency on Aging?(Required)

Are you partnering with a AAA?(Required)

If yes, please list them here:

What is the AAA's role in your community initiative?

Are you partnering with a local Alzheimer’s Association chapter or other national dementia-focused organizations?(Required)

If yes, please list them here:

What is this organization's role in your community initiative?

Are you partnering with a local age-friendly community initiative?(Required)

If yes, please list them here:

What is the local age-friendly organization's role in your community initiative?

Please upload your 3 Letters of Support here (including a letter from your state lead, if one is active in your state):(Required)

Upload your supporting materials in .pdf, .doc or .docx format

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

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