Alzheimer Society of Canada

*1.

Question - Required - 1. Thinking back to your first donation to the Alzheimer Society, what motivated you to give to this cause? Check all that apply.

	I'm living with dementia
	I lost someone to dementia or Alzheimer's disease
	I am concerned about one day being diagnosed with dementia
	I know that Canada is facing a dementia crisis and I want to help
	I want to ensure families affected by dementia get the support they need
	I want to support research to help find a cure for dementia
	Other

2.

Question - Not Required - Other

(Maximum response 255 chars, approx. 5 rows of text)

*3.

Question - Required - 2. If someone you know has been affected by dementia, what is their relation to you?

Parent

Grandparent

Spouse/Partner

Friend

Other

None

Prefer not to say

4.

Question - Not Required - Other

(Maximum response 255 chars, approx. 5 rows of text)

5.

Question - Not Required - 3. We'd like to hear your story. If you're comfortable sharing, tell us what impact Alzheimer's disease or dementia has had on you personally.

*6.

Question - Required - 4. Have you, or anyone you know, used any Alzheimer Society services?

Yes

No

5. On a scale of 1 to 5, how much would you agree to each statement?

*7.

Question - Required - The Alzheimer Society is at the top of my charity giving list 1 Strongly Disagree
2 Somewhat Disagree
3 Neither Agree nor Disagree
4 Somewhat Agree
5 Strongly Agree

*8.

Question - Required - I understand how my support is making a difference in people's lives 1 Strongly Disagree
2 Somewhat Disagree
3 Neither Agree nor Disagree
4 Somewhat Agree
5 Strongly Agree

6. Many of our supporters are interested in learning about other ways to give.
Please indicate which, if any, of the following interest or apply to you:

*9.

Question - Required - Monthly giving - provide steady funding for research and support programs.

I'm interested in becoming a monthly donor

I already make monthly donations but am open to increasing my monthly gift

I'm not interested in becoming a monthly donor at this moment.

*10.

Question - Required - Gift in your Will - make a lasting impact on future generations.

I'm interested in including the Alzheimer Society in my Will

I have already included the Alzheimer Society in my Will

I'm not interested in making a donation to the Alzheimer Society in my will at this moment.

*11.

Question - Required - Significant gift - make a difference for people living with dementia.

I'm interested in making a donation of $5,000 or more

I'm not interested in making a major gift at this time

7. Tell us more about you.

*12.

Question - Required - Age bracket:

Under 40

40-55

56-65

66-75

Over 75

Prefer not to say

*13.

Question - Required - Relationship and family status. Check all that apply:

	Single
	Married
	Life partnership
	Separated or divorced
	Widowed
	Have children
	Have grandchildren
	Prefer not to say

14.

Question - Not Required - 8. Is there anything else you would like us to know?

15.

Survey submitted by:


*	First Name: Required
*	Last Name: Required
*	Email: Required
	I give the Alzheimer Society of Canada permission to send me news, tips and information by email so I can stay up to date on what's happening across the country.

If you have questions regarding the survey, please contact Jeanelle Bertheau at 1-800-616-8816, ext. 2953 or by email at jbertheau@alzheimer.ca. Any information you provide will be kept completely confidential and will not be disclosed publicly without your consent.

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