Request a Dementia UK representative

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Name

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I understand that Dementia UK representatives are volunteers and there may be occasions when it is not possible to provide a volunteer.*

I confirm I understand

What's your name?

First Last

Name of your organisation (if applicable)

Name of your contact at Dementia UK*

Please supply your email address below*

Please supply your telephone number*

What date would you like a representative to attend?*

Is there an alternative date on which a representative can attend?

Event location*

Event location address*

Street Address Address Line 2 Town/City Post code Country

What are the timings of your event?*

Please provide an overview of your event

How many people will be at the event?*

How much are you hoping to raise?*

How can a representative help?*

Other:

If you are requesting a talk, please provide details (how long for, what you would like it to cover, equipment available etc)

Anything else you would like to make us aware of?

Dementia UK are committed to protecting your personal data. Please view our full privacy notice. If you would like to change how you are contacted by us, simply contact our Supporter Care team 0300 365 5500 or email supportercare@dementiauk.org.

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