PD Active Community Form
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Last Name *
First Name *
Address Street *
Address City *
Address Zip *
Phone Number
Phone Number Type
E-mail Address *
Tell Us About Yourself
Why are you interested in PD Active? *
Date of Diagnosis of Parkinson’s disease or Parkinsonism
For you, your partner or family member. An approximation is sufficient.
If you're not the person diagnosed with Parkinson's disease, would you please share that person's name?
How did you learn about PD Active? *
Please add the names of people or organizations from the list above.
I would like more information about:
Are You Newly Diagnosed With Parkinson’s?

A volunteer greeter from PD Active is available to talk to you about Parkinson’s disease and help you find your way forward. 

Would you like a greeter to call you? 

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Which of the following best represents your racial or ethic heritage?  Select all that apply
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This form was created inside of PD Active.