Dementia Friendly PA - Pledge Form

Pledge Form

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Welcome to the growing network of Dementia Friendly Pennsylvania Communities. Please complete the form below after participating in a discovery meeting with Dementia Friendly Pennsylvania.

Our community pledges to establish dementia friendly efforts to optimize the health, well-being, and community engagement of people living with dementia and those important to them.

Every part of the community plays a role and together we will work to take steps to create a dementia friendly culture and facilitate the adoption of dementia friendly practices.

We agree to:

Create and Maintain a Cross-Sector Community Action Team – Work to have people living with dementia, those important to them, and current or former care partners represented on the Community Action Team as they are at the heart of this work. Ideally, several community sectors are represented as well. No one single organization can be responsible for change across a community.

Engage with Community Members – Engage the broader community in a dialogue to learn community strengths, gaps, and priorities for action. Draft a vision statement and logo with consensus from the Community Action Team.

Develop an Action Plan & Begin Implementation – Create a community action plan that includes objectives, activities to meet the objectives, and a timeline. Select one or two realistic goals to start.

Track your Progress - Celebrate your successes! Increase awareness of your dementia friendly efforts by communicating your progress. Inform key collaborators of where change and impact are occurring within the community.

Identify Opportunities to Continue to Improve – Continue to use the community action plan as a guide to assess new opportunities that arise as activities are completed and objectives are met. Expand your team by inviting other key community members who have specific skills, knowledge, or connections to help implement the action plan.

Complete an annual Dementia Friendly Pennsylvania Survey – Each dementia friendly community will complete a brief survey capturing their progress for the year.

Apply to Dementia Friendly America within 2 years – With the support of the Dementia Friendly Pennsylvania team, each Dementia Friendly Pennsylvania Community will strive to apply to the National Dementia Friendly America Network within two years of acceptance into Dementia Friendly Pennsylvania.

Uphold a Code of Conduct - Maintain a culture of respect, integrity, inclusivity, and professionalism. All members are expected to act ethically, treat others with dignity, and maintain a safe and welcoming environment. All members of the community will refrain from acting in any way that could bring Dementia Friendly America, Dementia Friendly Pennsylvania, or the Jewish Healthcare Foundation into disrepute.

Do you agree to all the pledges?

Contact information for the person submitting this pledge:

First Name*

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Last Name*

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Email Address*

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Phone Number*

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Your Title*

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Your Organization*

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Dementia Friendly Location:

Proposed Dementia Friendly Pennsylvania Community Name:*

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Location of Pennsylvania Community (city, township, county)*

Please enter the Location of Pennsylvania Community.

Dementia Friendly Community Leaders:

Do you have any Co-Leads?*

Yes

Do you have any Co-Leads?

If Yes, how many Co-Leads?*

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Name of Co-Lead 1*

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Email of Co-Lead 1*

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Phone of Co-Lead 1*

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Organization of Co-Lead 1*

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Name of Co-Lead 2*

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Email of Co-Lead 2*

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Phone of Co-Lead 2*

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Organization of Co-Lead 2*

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Name of Co-Lead 3*

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Email of Co-Lead 3*

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Phone of Co-Lead 3*

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Organization of Co-Lead 3*

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Contact Signature*

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Co-Lead 1 Signature*

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Co-Lead 2 Signature*

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Co-Lead 3 Signature*

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