Dementia Essentials Expression of Interest

Is this training for?*

Yourself (or an individual)

Your staff (organisation/workplace)

Are you a decision-maker in your organisation?*

Yes

No

Thank you for your Interest in Dementia Essentials (CHCAGE005 Provide support to people living with dementia).

This is a Dementia Training Australia (DTA) course, funded by the Australian Government under the Dementia and Aged Care Services Fund and delivered by Dementia Australia. Completing this form will connect you through to Dementia Australia, who will contact you to schedule the training.

Please complete the form below to register your interest.

Name*

First Last

Email*

Phone*

Please exclude country code from number

I am interested in the delivery option*

Your State*

Postcode*

Position*

Organisation Name*

Organisation Full Address*

Please include street number and suburb.

Facility Name, if different

Facility Address, if different

Please include street number and suburb.

Care Setting*

Other, please specify*

Please briefly outline what you are hoping to achieve through the training.*

How did you find out about DTA?*

I have been referred by Dementia Support Australia (DSA)

DTA Website

Previous Contact with Dementia Australia (DA)

Previous Contact with DTA

Marketing Campaign

Other

If other, please specify

Do you have anything else to add?

Yes, show additional notes field

Additional Notes

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