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Caregiver Form

SCAN recognizes that taking on the responsibility of caring for a family member or friend can be difficult. Because of that, we look to work with our caregivers, whether you are providing support for one of our members, or you are a member who helps a loved one manage their health or household. To do that, we would like to know more about you. Please take a few minutes to fill out our Caregiver Form below. We hope we are able to get to know you a little bit better this way to help meet your needs and provide you with appropriate resources.

Name of the person you help care for:

If yes, a SCAN team member will call you to provide more information and registration within the next 3 business days.

If yes, a SCAN team member will call you to provide more information and registration within the next 3 business days.

By completing this form you have agreed to have our Caregiver Workshop coordinator contact you to complete the registration for workshops you wish to join. Please note: Only one form needs to be filled out per person.

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We're happy to help today. Call Member Services:

(800) 559-3500 TTY: 711 

Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31.

From April 1 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday. Messages received on holidays and outside of our business hours will be returned within one business day.

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