NeuroGroove Summer 2017
What is your name or the name of your loved one who would like to enroll? *
Your answer
Age and diagnosis (be as detailed as you would like) *
Your answer
What motor issues do you hope to address in this group? *
Your answer
I am registering for: *
What is your preferred music (songs, artists or genres)?
Your answer
How did you hear about NeuroGroove?
Your phone number *
Your answer
Your email *
Your answer
I understand that my place is not reserved until payment is received through the Paypal link below. *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.