Application Your Name: * Email: * Phone Number: * Your Address: * Which address would you prefer your Course Materials be mailed to? (If different from above) What is your current position at your nursing school? * I am applying as a(n): * Nurse Faculty Auditor ($200 Fee) I confirm, I am applying for the following program: * Muhammad Ali Parkinson Center at Barrow Neurological Institute • Monday – Wednesday, Sept 23-25 2024 University of Pennsylvania /Philadelphia VA Parkinson's Disease Research, Education and Clinical Center • Monday – Wednesday, Oct 21-23 2024 University of Toledo College of Medicine and Promedica Neuroscience Center • Monday – Wednesday, August 19-21 2024 Medical University of South Carolina/ Ralph H Johnson VA Medical Center • Monday – Wednesday, Nov 4-6 2024 Park Nicollet Struthers Parkinson's Center • Monday – Wednesday, May 19-21 2025 Please choose one or more to describe your ACADEMIC DEGREES: * PhD DNP EdD MPH MSN BSN AA Other (Please Specify) Please choose one or more to describe your ACADEMIC DEGREES: Other (Please Specify) Please choose one or more to describe your CREDENTIALS: * RN APN ARNP CRNP FNP GNP ANP CNS N/A Other (Please Specify) Please choose one or more to describe your CREDENTIALS: Other (Please Specify) How did you hear about this program? * Colleague EJS Brochure AACN Syllabus AANN Calendar Geriatric Advanced Practice List Serve MDS SIG for Health Professionals List Serve Email from Gina Dyer or Gwyn Vernon Email from Parkinson's Foundation (PF) PF website Moving Day Team Training for Parkinson's (Formerly ATTP©) LinkedIn Ad FaceBook AD Other (Please Specify) How did you hear about this program? Other (Please Specify) I agree that PF may keep copies of images or recordings of me, and may archive them so that they can be used to support the mission of Parkinson's Foundation. * Yes, I agree. No, I do not. Should you be accepted into the program, we would like to reach out to the Communication/PR office at your university to highlight your acceptance and involvement in this prestigious program. Please indicate if this is something you would be interested in having us contact you about. * Yes, should I be accepted into the program, I would be pleased to work with you to share news of my acceptance and involvement in the program highlighted in the University News No, I would prefer that you not contact my University about my acceptance. Are you a veteran of the US military? * Yes No Attach Resume/CV * Files must be less than 2 MB.Allowed file types: txt html pdf doc docx. Attach Letter of Interest * How will this program help your teaching? Please attach in PDF, .doc, or .docx format.Files must be less than 2 MB.Allowed file types: pdf doc docx. Attach Reference Letter * Please attach one file in PDF, .doc,. or .docx format.Files must be less than 2 MB.Allowed file types: pdf doc docx. Leave this field blank
