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MEMBERSHIP APPLICATION

Enjoy all that Parkinson Place has to offer for FREE

Name *

First

Last

Caregiver's Name *

First

Last

Relationship to Caregiver

Address

Phone Number *

Caregiver's Phone Number

Primary Email *

Caregiver's Email

We use Zoom for all of our online classes/support groups. Would you like someone to contact you to give you instructions on how to use Zoom?

Yes
No, I already know how to use Zoom

If referred by a physician, which physician referred you?

How did you hear about Parkinson Place?

Email

*Please note: When Parkinson Place reopens a full application will be required to complete. Thank you!

Address
5969 Cattleridge Blvd #100
Sarasota, FL 34232

Phone:
(941) 893-4188

Parkinson Place, Inc. Is a registered 501(c)(3) non-profit corporation. A copy of the official registration and financial information may be obtained from the division of consumer services by calling toll-free within the state (1-800-help-fla) or on the consumer services website www.800helpfla.com. Registration does not imply endorsement, approval, or recommendation by the state.

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