Activity registration | Parkinson Montréal-Laval

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Course registration

Civility *

First Name *

Last name *

Gender *

Female

Male

Non-binary

Autre

Date of birth *

Phone *

Email *

Address *

Appartment number

City *

Post Code *

Preferred language *

Year of diagnosis

Link with Parkinson *

Name of emergency contact *

Link with emergengy contact *

Emergency contact phone number *

Mobility *

Other mobility, specify

Do you have any other health issues or limitations related to the activity offered in this course (such as heart disease, osteoporosis, surgery, or injuries from a fall within the past five years, etc.)

Other health issues *

oui

non

If yes to other health problem, specify

By registering for activities offered by Parkinson Montréal-Laval, I understand that participation involves certain risks, and I release the organizations and their staff from any liability in case of injury. I consent to the sharing of the information in this form between the involved organizations, solely for the purpose of participating in the courses. I agree to inform Parkinson Montréal-Laval of any changes to my contact information or health status.

Consent *

yes

I would like to receive Parkinson Montréal-Laval’s newsletter, which includes information about class schedules, registration periods, and more.

Consent email *

yes