ACT NOW. Pledge to take action to reduce your risk of dementia.

Name:

Postcode:

Age:

I will start by (please select and tick all that apply):

being more physically active (walk/run more; join fitness class; family bike rides)
being more socially active (join a local club or class; see friends & family more often)
booking a health check or check BMI (blood pressure, weight, dental, cholesterol)
trying new things (classes, adult education courses)
reducing and stopping smoking
drinking less alcohol, if at all or watching my weight

I would like to receive information on the following that can help me:

I would prefer to receive this information by:

Email:
Postal address:

I am interested in supporting this campaign by sharing my story:

Comments:

What will we do with this information?

Once completed this form will be sent to the Welsh Government.

The Welsh Government will use this information to evaluate and improve the Dementia Risk campaign. We will also use your information to provide any additional information you requested on this form.

If we need to share your personal information with a partner organisation such as Stop Smoking Cymru, Drink wise Wales etc. we will contact you first to make sure that you’re content for us to do so.

If you have told us that you are interested in sharing your story, we’ll contact you to discuss this further.

If you provide us with your contact details, we may contact you in the future to see if you need any further information to reduce your dementia risk.

We will never sell your personal information and we won’t pass it on to anyone without your agreement.