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 
                  
                    Other 
                  
                   
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              Place of Residence
              
                * 
              
             
          
                
                
                
                  
                    I am a senior living in a retirement home 
                  
                    I am a senior living in a long-term care facility 
                  
                    I am a senior living in my own home 
                  
                    I am a senior living with a family member in their home 
                  
                    I am a care partner 
                  
                    I am a recreation manager at a LTC home 
                  
                    Other 
                  
                   
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              Emergency Contact
              
                * 
              
             
          
                
                
                  
                    First Name 
                   
                
                
                  
                    Last Name 
                   
                
               
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              Emergency Contact Phone Number
              
                * 
              
             
          
                
                
                
                  
                    (###) 
                   
                
                
                  
                    ### 
                   
                
                
                  
                    #### 
                   
                
               
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              WAIVER & ACKNOWLEDGEMENT
              
                * 
              
             
          
                
                
                
                
                
                
                
                
               
            
            
            
            
            
            
            
            
        
         
      
      
      
      YOU ARE REGISTERED! 
Here is your Zoom link:  https://us02web.zoom.us/j/81799290846 
Save this Zoom link!  Copy and paste the above link to save it on your desktop, in your notes, or in a folder for easy access every time you want to attend the Broadway Dance class.Is this your first time joining this class?  You will receive a confirmation email with all the information you will need prior to attending.