Application 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 or institution? * I am applying as a(n): * Nurse Faculty Nurse Educator Auditor I confirm, I am applying for the following program: * Muhammad Ali Parkinson Center at Barrow Neurological Institute - Phoenix, AZ • January 12-14, 2026 The Parkinson's Disease & Movement Disorders Institute at Weill Cornell Medicine - New York, NY • March 2-4 2026 Stanford Movement Disorder Center - Palo Alto, CA • May 13-15 2026 OHSU Parkinson Center - Portland, OR • June 15-17, 2026 BU Parkinson's Disease and Movement Disorders Center - Boston, MA • August 17-19, 2026 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 Nurse Association List Serve MDS SIG for Health Professionals List Serve Email from Gina Dyer or Annie Li Wong 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) Were you referred to this program by a previous attendee? * Yes No Please provide the name of the person who referred you: How much time is spent on teaching Parkinson's content at your institution each year? * <5 min 5 min 10 min 15 min Other... How much time is spent on teaching Parkinson's content at your institution each year? Other... In which course or training is this content covered? * 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
