Name(Required) First Last Date of Birth(Required) Month Day Year Gender(Required)FemaleMalePrefer not to sayOtherI have…(Required) Epilepsy Non-epileptic seizures Both Epilepsy and non-epileptic seizures Your Email Address(Required) Email Address Confirm Email Address Your Phone(Required)Your Address(Required) Street Address Address Line 2 City ZIP Code Emergency ContactPlease provide information for your emergency contact.Emergency Contact(Required) First Last Emergency contact relationship(Required)Emergency contact phone number(Required)Participation QuestionsWhat season would you prefer to participate (you can choose more than 1). *(Required) Winter (January – February) Spring (March – May) Summer (June – August) Fall (September – November) You can choose more than 1What time would you prefer to meet? The sessions last an hour (you can choose more than 1). *(Required) Morning (9:00 – 12:00) Afternoon (12:00 – 2:00) Late Afternoon (2:00 – 4:00) Evening (4:00 – 6:00) Optional Information to Help Sustain This ProgramSome of the questions below are optional and relate to demographic information. Our funding partners ask us to report this information in summary form. Sharing your responses—if you’re comfortable—helps us continue offering this program and reach more people who need it.Race/Ethnicity American Indian/Alaskan Native Asian/Pacific Islander Black/African American Hispanic White/Caucasian Prefer Not to Answer Multiple Ethnicity/Other What is your approximate average household income $0 – $24,999 $25,000 – $49,999 $50,000 – $74,999 $75,000 – $99,999 $100,000 – $124,999 $125,000 – $149,999 $150,000 – $174,999 $175,000 – $199,999 $200,000 & up Prefer Not to Answer What is your highest level of education? High School Diploma/GED Associates or 2yr Degree Bachelors or 4yr Degree Masters Degree Doctorate Degree Other
