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Please fill out the following form and submit to receive information, ask questions and/or if you have any comments or concerns.

We thank you for your interest in the PNR&D.

Name:
Address:
City: State: Zip:
Phone: Fax:
E-mail:
Please send me specific information about the following neurological diseases (check all that apply):

Alzheimer's disease
Amyotrophic Lateral Sclerosis (Lou Gehrig's disease)
Diabetic neuropathy
Huntington's disease
Multiple Sclerosis
Parkinson's disease

Please send me information about making a donation to the PNR&D. Yes No
Please send me information about volunteering for the PNR&D. Yes No
Please send me a copy of the PNR&D's quarterly newsletter highlighting progress made in the field of neurological disease free of charge.
 Yes No

Please put me in touch with a PNR&D faculty member.

 Yes No
Please schedule me for a tour of a PNR&D laboratory at the University of Michigan on Wednesdays from 12-2pm. Yes No
Additional Comments or Concerns: