Name:

Address:

Phone Number:

Email Address:

Preferred method of communication:

Email   Phone

 

What is your relationship to Parkinson's?
For example, are you a person with Parkinson's or Parkinsonisms,
caregiver/carepartner, spouse, family member, friend, etc.

Do you have any relationships with your Members of Congress or
other elected officials (local or national)?

Are you involved with other Parkinson's-related groups?

Do you volunteer or are you involved with other non-Parkinson's
organizations?

Do you belong to a support group?

Are you a veteran or active duty military?

Yes No

If yes, enter any related pertinent information below:

 

Have you completed the two trainings for PAN Assistant State
Directors (Congress and Community)?

Yes No

Why do you want to be an Assistant State Director? What skills
and experience do you bring to the role?

How much time are you willing to commit to this position?

Will you (check all that apply):

      Develop a relationship with your Representative and his/her staff?

      Complete PAN Action Alerts

      Communicate regularly with your State Director?

      Speak at support groups?

      Locate new support groups to speak to?

      Engage local print media (letters to the editor, op-eds)?

      Engage local television/radio?

      Use social media?

      Host tables at community events?

     Other:  

Are you currently receiving PAN Action Alerts?

Yes   No   Unsure

Do you have any questions or concerns?

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