Men of the Mountains: A Program for Men with MS

Program Registration

Date: Saturday, June 8, 2019

Time: 9am - 3pm

Location:
History Colorado Center

1200 N Broadway

Denver, CO 80203

Presentation Topics:

Cognitive Changes and Their Impact on Daily Life

Staying Active with MS

Sex, Drugs and... Diet

Support Partner Workshop

Please complete this form in its entirety to register for the Can Do MS Men with MS Program. The 2019 Men with MS program is organized by Can Do MS. The information below should be answered by the person with MS. Program participants must be male (support partners can be either gender). Program Participants and Support Partners must be at least 21 years old.

First Name: *

Last Name: *

Email Address: *

Phone Number: *

Address: *

City: *

State: *

Zip: *

Birthdate: (MM/DD/YYYY) * +

Gender: *

Date of Diagnosis: (MM/DD/YYYY) * +

Type of MS: *

How do you ambulate? *

Please specify your ethnicity: *

How many people are in your party (including yourself)? *

1 (yourself)

2

3