Survey - Pedaling for Parkinson's Wait List

Please share your name and contact information:

If you have previously registered, please login here to prepopulate your information.

Name:

First Name Required	Last Name: Required

Email: Required

Phone Number (555-555-5555):

Yes, I would like to receive future communications from Parkinson Canada.

Question - Required - Which day(s) do you plan to ride?
Please make at least 1 selection from the choices below.

	Friday
	Saturday
	Sunday

Question - Required - We encourage wait list registrants to commit to a $500 fundraising goal. What is your fundraising goal ($)?

Question - Not Required - Which location are you inquiring about (i.e. Alberta, Prince Edward County, etc.)

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Comments:

Pedaling for Parkinson's Wait List

Lead Sponsors