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DEFEAT PD Interest Form
Parkinson’s: Defeat PD
*
Indicates required field
Full Name
*
First
Last
I am inquiring about Defeat PD for:
*
Myself
A loved one
A friend
Registration is required for this class.
Candidates must sign and return a digital welcome packet with intake forms that are completed online. Once received, one of our specialized trainers will perform a brief in-person movement assessment with each candidate at the YMCA.
Defeat PD is offered at multiple branches. Which location are you in interested in?
*
Greystone YMCA (5414 US-280, Birmingham, AL 35242)
Hoover YMCA (2250 John Hawkins Parkway Hoover, AL 35244)
Mountain Brook YMCA (2401 20th Pl S, Mountain Brook, AL 35223)
Pelham YMCA (2610 Pelham Pkwy, Pelham, AL 35124)
Trussville YMCA (5920 Valley Road, Trussville, AL 35173)
I don’t have a preference.
Email Address for Reply
*
Phone
*
Preferred Method of Contact
*
Email
Phone
Participant DOB
MM slash DD slash YYYY
Candidate Agreement
*
I understand that:
Candidates must have Parkinson’s diagnosis to participate in Defeat PD.
Candidates must sign and return a digital welcome packet with intake forms that are completed online. Online forms will be sent to you from our Parkinson’s Coordinator following review of this interest form.
Candidates must participate in a brief in-person movement assessment with one of our specialized trainers.
The YMCA recommends that all participants have the following abilities:
– Can get on and off of the floor with minimal assistance
– Can walk unassisted or with a device
– Can sit and stand alone or with minimal assistance
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