Request edit access
Charlotte County Distinguished Speaker Series Registration
Event Timing: Saturday October 12, 2019, 9am- 12pm
Event Address: Murdock Baptist Church 18375 Cochran Blvd., Port Charlotte FL
Contact us at (941) 926-6413 or
Guest Name ( Last, First) use N/A if NO GUEST:
Guest Mailing Address :
Same as above
Guest Mailing Address ( if different) use N/A if NO GUEST :
Home Mailing Address:
Organization Affiliation ( if applicable):
I understand that by registering for this event, I agree and consent that Neuro Challenge Foundation for Parkinson's may take and use photos or videos from this event for educational and promotional purposes. This consent is given to me without limitations. I have read and agree to this statement.
How did you hear about this event?
Email from Neuro Challenge Foundation for Parkinson's
Neuro Challenge Foundation for Parkinson's Website
Please select your main reason for attending:
I am a Person with Parkinson's
I am a Care Partner
I am a member of the Medical Community
THANK YOU TO OUR PRESENTERS AND SPONSORS!
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Neuro Challenge.
Terms of Service