Caregiver Support: Online Registration Form (2020)

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Page 1

Take Care of Yourself and Others!

St. Francis Healthcare System simplifies the art of caring for yourself and those you love.
All classes are just $10 each and are held at the St. Francis Kūpuna Village in Liliha.

Course Selection

Which Course would you like to register for?

Please refer to the course details and dates below.

Page 2

Participant Information

First Name

Middle Name

Last Name

Birth Date

Email Address

Gender

Address

City

Zip Code

Phone Numbers:

Cell

Home

Business

How did you hear about Caregiver Support?

Class Date

Course Name

Student Information

Please provide the following information to assist the instructor in preparing for the class.

Who are you caring for? (e.g. Mother)?

How old is your loved one needing care?

Are you providing care with the help of others or by yourself at home?

Check all that apply:

Provide care aloneProvide care with other informal or unpaid caregiversPaid caregivers

Does your loved one receive any services from the community?

Please select the number corresponding to your loved one's ability to perform the following activities on a 1 (DEPENDENT) to 5 (INDEPENDENT) scale.

We ask that you share the major medical obstacles or chronic condition that you are helping to manage for your loved one. Please briefly explain:

What difficulties are you having in assisting your loved ones in functional tasks such as walking, transfers, etc.? (Physical Therapy)

Course Description

St. Francis Healthcare System offers informative sessions by experts for family caregivers. Enjoy networking with other caregivers facing the same challenges! Each class is $10. All classes are held at the St. Francis Kūpuna Village, 2226 Liliha Street, Weinberg Building. If you are having issues registering, contact
Maylynn Wong at mwong@stfrancishawaii.org or (808) 547-8138.

Payment Information

How would you like to pay?

Credit CardCheck

Credit Card Information

Name on Card

Card Number

Code

Is your billing address different than what is listed on page one?

YesNo

Billing Address

First Name

Last Name

Address Line 1

Address Line 2

City

State/Province

Postal Code

Check Information

Please mail checks to the address below:

St. Francis Healthcare System

ATTN: Maylynn Wong

Caregiver Education

P.O. Box 29700 Honolulu, HI 96820

Please Note: your registration is not complete until we receive your payment. After St. Francis
has received payment, we will provide an email notification of completed course registration.

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Active Aging - Retire & Rewire courses	Palliative Care
Enhance Fitness	St. Francis Hospice
Enhance Wellness	Other
Family Caregiver Training

Less than $15,000	$50,000 to $75,000
$15,000 to $24,999	More than $75,000
$25,000 to $49,999

American Indian/Native Alaskan	Black/African American
Non-Minority (White, non-Hispanic)	White-hispanic
Asian	Native Hawaiian/Other Pacific Islander
Other	Unknown

Single (never married)	Married	Divorced
Partner/Significant other	Separated	Widowed or Widowered

Arthritis	Rhuematic Disease
Cancer	Diabetes
Heart Disease	Hypertension
Lung Disease / Breathing Problems	Depression
No Chronic Conditions

	1	2	3	4	5
Eating
Bathing
Dressing
Grooming
Toileting
Transfer out of bed
Prepare meals
Use Telephone
Handle Finances
Shopping
Housekeeping
Able to take medication
Laundry