Register for a free memory screening with AFA & Town of Babylon Please select the date and location you wish to get screened at:*Select date/locationOctober 17- Babylon Town HallOctober 30- North Amityville Senior CenterNovember 2- Wyandanch Nutrition CenterNovember 9- Tanner Park Senior CenterNovember 17- Spangle Drive Senior CenterName* 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* Are 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 How did you hear about this service?* AFA website/email/social media Town of Babylon From a news story (newspaper, TV, radio) From someone I know From another organization Gender*Please selectFemaleMaleNonbinaryPrefer not to sayAge* Δ
Register for a free memory screening with AFA & Town of Babylon Please select the date and location you wish to get screened at:*Select date/locationOctober 17- Babylon Town HallOctober 30- North Amityville Senior CenterNovember 2- Wyandanch Nutrition CenterNovember 9- Tanner Park Senior CenterNovember 17- Spangle Drive Senior CenterName* 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* Are 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 How did you hear about this service?* AFA website/email/social media Town of Babylon From a news story (newspaper, TV, radio) From someone I know From another organization Gender*Please selectFemaleMaleNonbinaryPrefer not to sayAge* Δ
