Name
*
First Name
Last Name
Email
*
Phone Number
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is your age range
*
Under 20 years old
21 - 30 years old
31 - 40 years old
41 - 50 years old
51 - 60 years old
61 - 70 years old
71 - 80 years old
81 - 90 years old
91+ years old
Prefer not to say
What is your gender
*
Female
Male
Other
Prefer not to say
What is your first language?
*
English
French
German
Italian
Spanish
Portuguese
Arabic
Mandarin
Cantonese
Punjabi
Hindi
Hindi
Other (please indicate below)
If you indicated "Other" above, please indicate first language below
How did you hear about our classes?
*
Parkinson Canada
Parkinson’s support group
Media
DWP website
Care partner
Seniors Residence/Facility
Friend/Family
Community Organization
Neurologist
General Practitioner/Nurse
Other
Choose from one of the options below:
*
I am a person living with Parkinson's disease
I am a senior (55+)
I am a care partner
I am a recreation manager at a LTC home
Other
Place of Residence
*
I live in a retirement home
I live in a long-term care facility
I live in my own home
I live with a family member in their home
Other
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
(###)
###
####
WAIVER & ACKNOWLEDGEMENT
*
I acknowledge that Dancing with Parkinson's is not responsible for any injury sustained during the course of a dance class. I assume all risks and liability for any injury resulting from engaging in any classes in person or online.
I agree that by completing this form I understand that I give Dancing with Parkinson's permission to email me about DWP classes and events. (Note: You may unsubscribe at any time, however we advise that you remain on our list for important notifications.)
For the purposes of providing the public an opportunity to learn more about DWP, I consent to the use of video/audio clips of me through print, electronic, audio, or video media. By giving this consent, I release DWP, its affiliated entities, and employees from any and all claims, demands, and liabilities arising from their use.