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.

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* 1. Title:

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* 2. First Name:

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* 3. Last Name:

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* 4. Street Address:

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* 5. City:

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* 6. Province:

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* 7. Postal Code:

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* 8. Telephone:

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* 9. Email:

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* 10. Federal Riding:

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* 11. Age:

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

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* 13. Have you previously volunteered for Parkinson Canada?

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

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* 15. How did you find out about the Ambassador program?

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

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

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* 18. Questions?

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* 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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