Supporter Application Form

Dementia Action Alliance Supporter Application Form

This type of membership is for organisations that may be supportive of creating a local alliance to become a dementia friendly community, but may not be in a position to become a full member of the Dementia Action Alliance and submit an action plan. Your organisation can only become a supporter if a Local DAA already exists in your area.

Once your application has been approved, your organisation will be listed on www.dementiaaction.org.uk under your local alliance webpage as a ‘Supporter’.

Information about you and your organisation

The organisation listed below agrees to sign up to the National Dementia Declaration and commit to becoming a Supporter of the Dementia Action Alliance. By becoming a Supporter, your organisation agrees to raise awareness of dementia and/or support people with dementia and their carers. Please tick [P ]

Fill in your contact details

Name of organisation: / Age UK East Sussex
Contact name: / Cornelia Dietze
Work address: / 54 Cliffe High Street
Lewes
East Sussex BN7 2AN
Phone: / 01273 476704
Email: /
Website: / http://www.ageuk.org.uk/eastsussex/

Are you willing for us to share your contact details with fellow Dementia Action Alliance members: Yes P No

Local Dementia Action Alliance you want to support:
Bexhill and Hastings

During 2014/2015, the organisation listed above agrees to carry out the following activities: (Please select at least one option from each of the four categories)

1.  Raise awareness of dementia to staff / Please tick
·  Encourage all staff to watch the Dementia Friends film at www.dementiafriends.org.uk or attend a face to face Dementia Friends session / ü 
·  Encourage all staff to participate in the SCIE eLearning resources www.scie.org.uk/publications/elearning/
·  Provide an alternative dementia awareness course. Please specify:
www.Kwango.com dementia training supported by East Sussex County Council
our own in-house training delivered by ‘Dementia Adventure’ / ü 
2.  Improve customer service and dementia friendly ways of working
·  Provide staff with access to the Alzheimer’s Society Customer Facing Staff Guide. Details can be found at www.alzheimers.org.uk/site/scripts/news_article.php?newsID=1935 / ü 
·  Provide training to staff members. Please specify: interaction & communication models; Memory/ Attention/ Language
·  Prevention - what works
·  Resources and further reading
·  Action plans / P
3.  Improve access and signage in your facilities/ environment
·  Carry out a review against the Dementia Friendly Environments checklist or similar www.dementiaaction.org.uk/assets/0000/4334/dementia_friendly_environments_checklist.pdf / ü 
·  Provide alternatives where possible to people living with dementia e.g. Display a coin recognition chart, on the day appointment reminders. Please specify: phone reminders for appointments / ü 
·  Other: Please specify:
1.  We have changed the flooring at our Hastings Day Care Centre to make the venue more dementia friendly
2.  Following our input on a national level, Age UK marketing templates have now been adjusted to make them more dementia friendly. The templates are being used by local Age UKs for producing their own marketing materials. / P
4.  Keep connected
·  Regularly visit www.dementiaaction.org.uk/dementiafriendly for more tips on becoming dementia friendly / ü 
·  Let other organisations know about the DAA so they can become part of their Local Alliance / ü 
·  Promote dementia friendly approaches through internal/external communications / ü 
Please add any local alternatives or additional activities you have completed or intend to undertake during 2014/2015 related to becoming Dementia Friendly:
·  Our day care staff and health activities staff have participated in training for conducting dementia friendly outdoor activities
·  Day care, health activities and office staff (as they are answering telephones) completed dementia awareness training
·  We have started delivering a bespoke dementia awareness training course supported through funding from Age UK
·  We aim to have a trustee become a dementia champion on our board

If your Local Dementia Action Alliance has signed up to the Dementia Friendly Communities Recognition Process, you may be eligible to use the ‘Working to become Dementia Friendly Symbol (2014/2015)’ subject to approval.

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Supporter Application Form

To see which communities are working to become dementia-friendly visit : www.alzheimers.org.uk/recognitionprocess

Please return this form to:

Your Local Dementia Action Alliance Coordinator. Please click here to find their contact details or visit www.dementiaaction.org.uk/local_alliances

Alternatively, you can return this form to the DAA Secretariat:

Email:

Post: DAA c/o Alzheimer’s Society, Devon House, 58 St Katharine's Way, London, E1W 1LB

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