Apply to the Alzheimer’s Society Research Network

Your details

About you

Complete

If you have a personal experience of dementia, either as a person with dementia, a carer or a former carer (unpaid/non-professional), you are eligible to become a volunteer in our Research Network. Once we receive your application, we will contact you directly regarding the next steps.

Please note, this application form includes questions about your background and your experience of dementia. This information will be kept confidential and is used to help us to match volunteers to projects and activities that are relevant to their experience of dementia.

We also ask for your details in order to contact you, keep you up-to-date and send further information.

To find out more about how we use your personal information, please read our supporter privacy statement.

If you do not wish to complete this form online, you can download, print and post a paper copy of the application form.

Title

First name

Last name

Address

Address 2

City/Town

Post Code

Phone number

Mobile phone number

Email address

Name of emergency contact

Alzheimer’s Society will need to know who to contact in the unlikely event of an emergency.

Phone number of emergency contact

Emergency contact's relationship to you (e.g. son, wife, partner)

Please clarify your contact preferences

Contact me by email only, please.

Contact me by post only, please.

Contact me by either email or post.

We contact Research Network volunteers with information relating to their role and to keep them informed about the wider work of the Society. How would you prefer to receive these communications?