Thank you for joining our Parkinson's Ambassador Network! Please take a moment to complete the following survey. All questions with an asterisk require an answer.

* 1. Title:

* 2. First Name:

* 3. Last Name:

* 4. Street Address:

* 5. City:

* 6. Province:

* 7. Postal Code:

* 8. Telephone:

* 9. Email:

* 10. Federal Riding:

* 11. Age:

* 12. What is your connection to Parkinson's disease?

* 13. Have you previously volunteered for Parkinson Canada?

* 14. If you answered 'Yes' above, please describe your volunteer involvement:

* 16. Would you like to receive future communications from Parkinson Canada?

* 17. Please provide a brief explanation why you want to be a Parkinson's Ambassador.

* 18. Questions?

* 19. Would you be comfortable having your contact information shared with other Ambassadors in both the same Province & Federal Riding as you?

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