Movers & Shakers Inc.

A National Young Onset Parkinson Disease Support & Advocacy Organization

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Are you?:	Person w/PD Professional Caregiver/Friend Other
Name: *
Mailing Address: *
City:
State: *
Zipcode: *
Phone Number:
E-mail Address: *
Cell Phone:
Screen Name (if different):
Would you like to receive information via email? *	Yes No
Professional Organization:
Website:
Date of Birth: *
Years Diagnosed *
Are you?	Married Single Divorced Widowed Partner
Occupation or Former Occupation: *
Number of Children & Ages:
Name of Neurologist: *
Are they a Movement Disorder Specialist?	Yes No I Dont Know
Local Support Groups you belong to:
Medications Currently Taking:
What can Movers & Shakers do to serve you?
Are you interested in becoming a State Advocate?	Yes No I need more information
Additional Comments:


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