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Parkinson's Pals Registration Form
Please provide us some more details about you and your background!
Reach out to 484-560-3085 or parkinsonspals@gmail.com if you have any questions!
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Email
*
Your email
Name
*
Your answer
Phone
*
Your answer
Are you a caretaker or family member of the pal interested?
*
Yes
No
Other:
If yes, could you provide us your name and contact info!
*
Your answer
Availabilities
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
8-10 AM
10-12 PM
12-2 PM
2-4 PM
4-6 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
8-10 AM
10-12 PM
12-2 PM
2-4 PM
4-6 PM
Please describe some interests and career paths you have had: (We will match you to a student with similar interests and career goals!)
*
Your answer
Do you have any questions or concerns?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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