First Name

Last Name

I am a:

How did you hear about Seizure Smart Classroom Kits?

Your Contact Information:

Yes, I would like to receive EFMN's monthly e-newsletter

Street Address

City

State

Postal Code

Phone

Demographic Information

Birthdate

What is your primary relationship to epilepsy?

Has Epilepsy (Self)Another Family Member Has EpilepsyChild Has EpilepsyFriend/Co-Worker Has EpilepsyLost Someone with EpilepsyParent Has EpilepsySpouse or Partner Has EpilepsyWorks with People with EpilepsyOther / Prefer Not to AnswerHelps us provide targeted resources and information. We do not share this information.

Gender

MaleFemaleNon-binaryPrefer to Self-DescribePrefer not to answer

Please describe:

Pronouns (optional)

example: she/her

Race

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMixed RacePrefer not to answer

Ethnicity

Hispanic, Latinx or Spanish OriginNot Hispanic, Latinx or Spanish OriginPrefer not to answer

EFMN is asking demographic questions to have a better understanding on who we serve. Although all questions are required, there is always a "Prefer not to answer" option if you choose to keep this information private.

The options for demographic questions are in accordance to the US Census Bureau.

Student with Epilepsy's Information (if applicable)

First Name

Last Name

Birthdate:

School's Information:

Tell us a little about the school & classroom you're requesting this Classroom Kit for:

Name of School:

Type of School:

Grade Level (that Classroom Kit is requested for)

Number of students (approximate) in class:

School Address

City

State

Postal Code

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Contact Information