EmailMe Form - Coffee Break® 2020 Registration Form

Any personal coffee breaks should be in accordance mandated physical distancing protocols, within your social bubble or virtually. There are many different video conferencing technologies available for you to choose from like Zoom, Skype, or Google Hangouts! Please contact us for a "How-To Use Virtual Video Conferencing Platforms Guide" if you need help choosing which platform would be best for you.

Checkbox *

I have read and understand the above notice

Name *

First Last

Organization/Club name (if applicable)

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Date of Coffee Break®

MM / DD / YYYY

The above is a firm date

The above is a tentative date

We want to hold a Coffee Break® but don't have a date yet

My fundraising goal:

I would like to have my Coffee Break® posted on the ASSC Coffee Break website *

Yes

No

The Alzheimer Society of Simcoe County has some items in stock to assist with your Coffee Break®. Limited quantities are available and will be offered on a first come first serve basis. Please check all those you are interested in.

Coffee

Donation Box

Forget-me-not cut-outs

I want to know more! I want to do more! Please contact me about:

Other Events

Other ways to help

Sign me up for ASSC's monthly newsletter

Alzheimer Society of Simcoe County
20 Anne St. S., Unit 3, P.O. Box 1414
Barrie, ON L4M 5R4
Phone: 705-722-1066
Toll Free: 1-800-265-5391
Email: events.simcoe@alzheimersociety.ca

Checkbox

First option

Second option

Third option