PPG Fitness Participant Information

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Email *

Date *

YYYY

First Name *

Last Name *

PPG Fitness Location *

Chicago - (Metro Area)

Peoria

San Bernadino

Los Angeles - Santa Monica (YMCA)

San Diego

Canoga Park - (Allen & Sons)

San Francisco Bay Area - (888)

Other

Phone Number *

Date of Birth: *

YYYY

Mailing Address: *

Emergency Contact, Phone Number & Relationship to You: *

How did you hear about us? *

Have you been cleared to participate in an exercise program by your primary care physician? *

Yes

Have you been diagnosed with Parkinson's Disease? *

Yes

Have you been diagnosed with a neuro degenerative or neurological conditions such as Alzheimer’s and/or related dementias? Or neurologic development disorders?

If yes, please describe:

What is your ping pong playing experience? *

I've never played

I played in my youth recreationally

I have played regularly

I play competively

Other:

If you played regularly, for how long? *

What do you wish to gain from participating in the PPG Fitness Program? *

Do you have questions or additional comments about the program? *

Would you like to be added to our PPG Member Contact List? *

Yes

A copy of your responses will be emailed to the address you provided.

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