Video vignettes submission form

Please complete the application form below so that we can use your submission

1. Full Name: Ángel Rafael Pereira Ramírez

2. Email address: angelrpr186@gmail.com

3. Language of submission: Español

Consent

I confirm my consent and provide permission for the video to be used as part of the World Alzheimer’s
Month campaign and the World Alzheimer Report 2021 in addition to subsequent campaigns. I also
acknowledge that these videos will be used by our associates, including McGill University, Montreal,
Canada or ADI membership associations.

Signature ………………………. Date: 21 de julio 2021

Alzheimer’s Disease International, The International Federation of Alzheimer’s Disease and Related Disorders Societies, Inc.
In official relations with the World Health Organisation.