Registration Enter your contact information First Name * User Email * Country * AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaSamoaYemenZambiaZimbabwe Last Name * Phone: *optional* Province / State * Choose your username and password Username * User Password * Confirm Password * Please tells us about yourself and your relationship to Parkinson’s disease. Your responses will remain anonymous. They will only be used to help us understand more about who is using the Parkinson’s Education Program (PEP) for Community Caregivers. This will help us improve the program to ensure we meet the needs of our users. Your data will not be shared with those outside of the Parkinson’s Education Program (PEP) for Community Caregivers support team. We appreciate your help! Age * 15161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100 Education * High School Diploma (or equivalent)2-year degree4-year degree Certificate programGraduate School I identify as: * MaleFemalePrefer not to answer I am a (check all that apply) *Physician/doctor Nurse PSW OT PT SLP Student Therapeutic Recreation/activity Professional Dietician Social Worker Neurologist Administrator Other How long have you been providing care to individuals with Parkinson’s disease? *1 year 1-5 years 5-10 years More than 10 years Not Applicable I am completing this program because I want to (check all that apply) *Continuing Education credit To advance my employment options To improve my caregiving skills To educate others Learn more about Parkinson’s disease How did you hear of PEP? *Parkinson Society Southwestern Ontario website A friend A colleague other When it comes to my understanding of Parkinson’s disease, I consider myself an *Expert Knowledgeable but definitely not an expert Just starting to learn about Parkinson’s disease How many hours per month do you spend providing caregiving duties to individuals with Parkinson’s disease? *1-5 hours 5-10 hours 10-15 hours 15-20 hours More than 20 + hours Not Applicable What is the level of physical burden associated with your caregiving duties (specific to PD) *Extremely high Very High Moderate Low none What is the level of impact on your physical/emotional health as a result of providing care to individuals with Parkinson’s disease? *Extremely high Very High Moderate Low none. Register
