Registration Completion for Let's Combat Micrographia® Live Virtual Workshop Series

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You are receiving this form to complete as you registered for our Let's Combat Micrographia® Live Virtual Workshop Series starting January 2021. We are excited to collaborate with Parkinson Care and Support UK!

We will be starting 2021 strong and will help you get back on track to improve your handwriting! We hope you are as excited as we are to participate in this one of a kind program! You can find more information about The Art Cart and our Let's Combat Micrographia Series at www.letscombatmicrographia.com

This workshop is only open to people living Parkinson's disease and the material that will be shared is proprietary and confidential. Please complete the form as soon as possible. Once your form is submitted we will mail your materials to you.

Email *

Full Name *

Emergency Contact Name, relationship, and number *

When were you diagnosed with PD? *

What limitations do you feel you have with PD? *

What are you hoping to gain from the Let's Combat Micrographia Workshop series? *

Please provide your FULL Mailing Address where we can mail your materials *

Participant Waiver-This must be signed off prior to starting the workshop series. This will enable us to start sending material your way.

Waiver Agreement and Acknowledgment *

By selecting this box, I have read, understand, and agree to the terms of this Participant Waiver & Consent. This will be in place of my physical signature.

Required

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

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