CB Moves Interest Form
We are excited to welcome you/your student! Registration for Youth and Adult classes begins in August for classes starting late September. Parkinson's classes are ongoing throughout the year on Mondays, Wednesdays, and Fridays at 2:15pm. Please fill out this form to indicate your interest, and we will contact you regarding pertinent programming.
Name
*
First Name
Last Name
Best Phone Number to Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best Email Address to Contact
*
example@example.com
I am filling out this form on behalf of:
*
myself
my child
my spouse/partner
my parent
Other
Participant Name
First Name
Last Name
Please contact me regarding classes for:
*
Youth (ages 4-18) with disabilities
Adults (ages 18+) with disabilities
Seniors
Persons with Parkinson's and carepartners
Individuals with Dementia or other memory concerns and carepartners
Other
Submit
Should be Empty: