Become an Advocate

Your first name

Your last name

Your email

Phone

Address

City

State
AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Zipcode

What year did you complete SPEAK OUT! Therapy? Type "N/A" if you are a family or friend.

Where did you complete SPEAK OUT! Therapy (Name of Clinic)? Type "N/A" if you are a family or friend.

When is the last time you attended the Learn About Parkinson's Webinar?

Click the activities you are currently participating in.
Online SPEAK OUT! Home Practice SessionsWeekly SPEAK OUT! GroupIntentional Singers at PVP ClinicOnline Parkinson's Sing AlongsNone

Please additional speech and physical exercise groups you participate in. (type "N/A" if you're a family or friend)

When is your birthday?

Are you retired or still working?

Occupation:

Please list your special skills:

Why are you interested in being an Advocate?

Are you interested in presenting to community groups (e.g. Rotary Clubs, church groups, PD support groups)?
YesNo

Do you want to join the In-Person or Virtual Advocate Group?
In-Person at PVP at 1st & 3rd Wednesdays at 11:15amVirtual Group on 1st & 3rd Wednesdays at 12:00pm CT