Resource Listings Request

Groups who wish to be added to the Parkinson's Foundation local resource listings are required to complete the following online screening questionnaire:

1. Have you submitted your group/program info in the past?

Yes, I am already listed but have a change to my group's informationNo, I am not listed but would like to be added

2. Group or Program Name:

2a. Program Phone Number (Public):

3. Is this group affiliated with a larger organization or non-profit?

YesNo

If 'Yes' - what is the Organization's Name?

4. In what year was this group established?

5. Name of Primary Contact

First

Last

6. Phone number:

7. Email Address:

8. Location of meeting or class

City

State

Zip Code

9. Link to Website (if available)

10. Brief description of the program or group:

11. Is there a fee for this class?

Yes, there is a feeNo, this class is free

12. Program/Group Type: (to select more than one, hold down the control key (PC) or the command key (Mac) while making your selections)

Additional Program Information: (to select more than one, hold down the control key (PC) or the command key (Mac) while making your selections)

If 'Other' is selected, please specify:

13. Is the class led by exercise professionals with certification accredited by the NCCA (or other 3rd party), or a current licensed healthcare provider?

YesNo

14. If the certified exercise professional or licensed healthcare provider received additional certification or continuing education credits in Parkinson's, which of the following Parkinson's-specific programs have they successfully completed? (*Parkinson's Foundation Accredited Exercise Education Provider)(to select more than one, hold down the control key (PC) or the command key (Mac) while making your selections)

Other Certification:

Attention:

I acknowledge that this information will be shared externally with constituents by inquiry request only. This information will not be published. The program submitted is provided with the highest standards for quality and safety. Additionally, the host organization/individual agrees to use transparent, supportive and open communication when speaking with others about the Parkinson's Foundation.

I accept

Parkinson's Foundation