WINSTON-SALEM RESPITE CLASS

DAYS AVAILABLE:
April 9; May 7; May 14; May 21; May 29*; June 4; and June 11.

*Please Note that his will be on a Tuesday because Monday, May 28 is Memorial Day and the Senior Services center will be closed.


For Care Receivers with a diagnosis of PD
as a respite service for the Care Partner participants of our
Winston-Salem
"PARTNERING WITH POISE"

Care Partner Class Participant - Please fill out this form in order for your care receiver (PlwPD) to be able to participate in any of the respite classes. Thank you!
Name of Care Partner Class Participant *
Name of Care Partner Class Participant
Name of Person Living with Parkinson's *
Name of Person Living with Parkinson's
Address *
Address
* PLEASE HAVE THE CARE RECEIVER ENTER THEIR NAME BELOW TO INDICATE THEY UNDERSTAND AND AGREE TO THIS WAIVER WITH THEIR NAME TYPED BELOW INDICATING THEIR AGREEMENT TO THIS RELEASE AND WAIVER.