Survey - Healthy Parkinson's Communities Initiative Interest Form

Healthy Parkinson's Communities Initiative Interest Form

Get Involved!
Are you interested in joining the Healthy Parkinson's Communities Initiative? Submit your interest using the form below! After sharing your information with us, you will receive a confirmation email with instructions on how to complete your application.

Please enter your name, location, and email:


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
*	Country: Required
	Phone Number:
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Question - Required - What is your relationship to Parkinson's?

Question - Required - What year were you diagnosed?

Question - Required - Are you currently employed?

Yes

Question - Not Required - What is your current occupation?

Question - Required - How did you hear about the Healthy Parkinson's Communities Initiative?