PACES and Project UPLIFT Inquiry Form - Epilepsy Foundation of Colorado and Wyoming

Name *

First

Last

Date of birth *

Email Address *

Phone *

Address *

City *

State *

Gender *

I have... *

Epilepsy
Non-epileptic seizures
Both Epilepsy and non-epileptic seizures

Emergency contact *

First

Last

Emergency contact relationship *

Emergency contact phone number *

What season would you prefer to participate in UPLIFT (you can choose more than 1). *

Winter (January – February)
Spring (March – May)
Summer (June – August)
Fall (September – November)

What time would you prefer to meet? The sessions last an hour (you can choose more than 1). *

Morning (9:00 – 12:00)
Afternoon (12:00 – 2:00)
Late Afternoon (2:00 – 4:00)
Evening (4:00 – 6:00)

Please indicate if you are interested in PACES or Project Uplift (or both). If you have any notes or specific questions about the program, please share:

This program is funded by external grants that require us to report demographic information as part of our program summary:

Race/Ethnicity

What is your approximate average household income

What is your highest level of education?