First Name

Last Name

Company Name (if applicable):

Are you over 18?

YesNo

Birthdate:

Volunteers under 18 are required to obtain parent/guardian consent.

What is your relationship to epilepsy?

I have epilepsy/seizuresMy child has epilepsy/seizuresMy parent has epilepsy/seizuresMy spouse or partner has epilepsy/seizuresAnother family member has epilepsy/seizuresA friend/co-worker has epilepsy/seizuresI work on behalf of people who have epilepsy/seizuresOther/prefer not to respond

Contact Information:

Email

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Phone

Street Address

City

State

Postal Code

Volunteer Information

Please select your first volunteer preference:

Please select your second volunteer preference:

Please select your third volunteer preference:

Please list any past volunteer experience you have:

Please let us know about any accommodations you may need to perform a volunteer job:

Do you have training or experience that you are willing to share with EFMN? (please select all that apply by holding down the CTRL button with your selections):

Will you be receiving academic credit/community service hours for your volunteer work?

YesNo

Please describe:

Emergency Contact Information

Emergency Contact Name:

Phone

Emergency Contact's relationship to you:

Waiver/Release

The Epilepsy Foundation of Minnesota has permission to use photographs, videotapes, and testimony from me during program activities for use in any agency publications, presentation, or digital applications.

Please type your name/electronic signature here:

Parent/Guardian electronic signature here: