Dementia Friendly PA - Pledge Form

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Welcome to the growing network of Dementia Friendly Pennsylvania Communities. Please complete the form below after participating in a discovery meeting with Dementia Friendly Pennsylvania.

Our community pledges to establish dementia friendly efforts to optimize the health, well-being, and community engagement of people living with dementia and those important to them.

Every part of the community plays a role and together we will work to take steps to create a dementia friendly culture and facilitate the adoption of dementia friendly practices.

We agree to:

Create and Maintain a Cross-Sector Community Action Team – Work to have people living with dementia, those important to them, and current or former care partners represented on the Community Action Team as they are at the heart of this work. Ideally, several community sectors are represented as well. No one single organization can be responsible for change across a community.

Engage with Community Members – Engage the broader community in a dialogue to learn community strengths, gaps, and priorities for action. Draft a vision statement and logo with consensus from the Community Action Team.

Develop an Action Plan & Begin Implementation – Create a community action plan that includes objectives, activities to meet the objectives, and a timeline. Select one or two realistic goals to start.

Track your Progress - Celebrate your successes! Increase awareness of your dementia friendly efforts by communicating your progress. Inform key collaborators of where change and impact are occurring within the community.

Identify Opportunities to Continue to Improve – Continue to use the community action plan as a guide to assess new opportunities that arise as activities are completed and objectives are met. Expand your team by inviting other key community members who have specific skills, knowledge, or connections to help implement the action plan.

Complete an annual Dementia Friendly Pennsylvania Survey – Each dementia friendly community will complete a brief survey capturing their progress for the year.

Apply to Dementia Friendly America within 2 years – With the support of the Dementia Friendly Pennsylvania team, each Dementia Friendly Pennsylvania Community will strive to apply to the National Dementia Friendly America Network within two years of acceptance into Dementia Friendly Pennsylvania.

Do you agree to all the pledges?

Contact information for the person submitting this pledge:

First Name*

Please enter the contact's first name.

Last Name*

Please enter the contact's last name.

Email Address*

Please enter the contact's valid email address.

Phone Number*

Please enter the contact's valid phone number.

Your Title*

Please enter your title.

Your Organization*

Please enter your organization.

Dementia Friendly Location:

Proposed Dementia Friendly Pennsylvania Community Name:*

Please enter the proposed Dementia Friendly Pennsylvania Community Name.

Location of Pennsylvania Community (city, township, county)*

Please enter the Location of Pennsylvania Community.

Dementia Friendly Community Leaders:

Do you have any Co-Leads?*

Yes

Do you have any Co-Leads?

If Yes, how many Co-Leads?*

Invalid Input

Name of Co-Lead 1*

Please enter name of Co-Lead 1.

Email of Co-Lead 1*

Please enter email address of Co-Lead 1.

Phone of Co-Lead 1*

Please enter phone of Co-Lead 1.

Organization of Co-Lead 1*

Please enter Co-Lead 1 organization.

Name of Co-Lead 2*

Please enter name of Co-Lead 2.

Email of Co-Lead 2*

Please enter email address of Co-Lead 2.

Phone of Co-Lead 2*

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Organization of Co-Lead 2*

Please enter Co-Lead 2 organization.

Name of Co-Lead 3*

Please enter name of Co-Lead 3.

Email of Co-Lead 3*

Please enter email address of Co-Lead 3.

Phone of Co-Lead 3*

Please enter phone of Co-Lead 3.

Organization of Co-Lead 3*

Please enter Co-Lead 3 organization.

Dementia Friendly Partnerships:

Is your organization an Area Agency on Aging (AAA)?*

Yes

Please answer if your organization is an Area Agency on Aging (AAA).

Have you contacted your local AAA to become involved? *

Yes

Please answer if you have contacted your local AAA to become involved.

If Yes, please list the AAA*

Please list the AAA contacted.

Are you partnering with a local Age-Friendly community initiative?*

Yes

Please answer if you are partnering with a local Age-Friendly community initiative.

If Yes, please list the initiative*

Please list the initiative(s).

We now hereby sign this pledge as a commitment to continue in our efforts to make and sustain our Dementia Friendly Community.

Contact Signature*

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Please have the contact person sign the pledge form.

Co-Lead 1 Signature*

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Please have Co-Lead 1 sign the pledge form.

Co-Lead 2 Signature*

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Please have Co-Lead 1 sign the pledge form.

Co-Lead 3 Signature*

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Please have Co-Lead 3 sign the pledge form.