In-Person Memory Screening Appointment Request Please select your preferred date (not guaranteed)*November 3rdNovember 10thNovember 17thNovember 24thThe event will run from 10am - 2pm with each screening being in 30-minute intervals. Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email address* This field is hidden when viewing the formAre you a veteran or an immediate family member of a veteran?* Yes, I am a veteran Yes, I am an immediate family member of a veteran No, I am not This field is hidden when viewing the formHow did you hear about this service?* AFA website/email/social media From a news story (newspaper, TV, radio) From someone I know From another organization Gender*FemaleMaleNonbinaryPrefer not to sayAge* Δ Please share this page with your loved ones and colleagues!