RECORDING Request for Seizure Smart Training
Video Requested
Please select...
Seizure Smart Basics (30 minutes)
Seizure Smart Training (60 minutes)
Seizure Smart School Personnel Training
Seizure Smart School Nurse Training
Seizure Smart Childcare Personnel Training
Seizure Smart High School Training
Seizure Smart Elementary School Training
Seizure Smart Transportation Training
Seizure Smart Older Adults Training
Seizure Smart Workplace Training
Take Charge of the Epilepsy Facts 6th - 10th Grade Training
Camp Training
Video Request Link
First Name
Last Name
Email
Phone
Zip Code
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Organization/Employer
If none, please leave blank.
Industry Type
Please select...
Affiliate
Business
Clinic
College/Higher Ed
Corporate
County Social Services
Education: Day Care/Head Start
Education: District School/Area School
Education: Elementary School
Education: High School
Education: Middle/Jr High School
Fire/Police/Emergency Personnel
Foundation
Government
Group Home
Home Health Care/Adult Day Service
Hospital
Media
Mental Health Services
Nonprofit
Religious Organization
Secondary Clinics
Senior Serving Organization
Service Club
Vendor
Youth Organization
Other
Please specify:
How many individuals will be viewing this video?
What is your primary relationship to epilepsy?
Has Epilepsy (Self)
Another Family Member Has Epilepsy
Child Has Epilepsy
Friend/Co-Worker Has Epilepsy
Lost Someone with Epilepsy
Parent Has Epilepsy
Spouse or Partner Has Epilepsy
Works with People with Epilepsy
Other / Prefer Not to Answer
Is this your work email?
Please select...
Yes
No
Email listed above
Work Email
How did you hear about this webinar?
Please select...
EFMN E-Newsletter
EFMN Events Newsletter
EFMN Staff
EFMN Website
Employer
Eventbrite
Physician
Social Media
Staff Member Name
Would you like a Certificate of Completion?
Yes
No
Please read the statements below and select the one that applies.
I consent to receive SMS text communications from the Epilepsy Foundation of Minnesota (EFMN) at the phone number provided above. I understand that messaging frequency may vary, and message & data rates may apply. Reply STOP to opt out of SMS text messages at any time.
I do not consent to receive SMS text communications from the Epilepsy Foundation of Minnesota at the phone number provided above.
Contact Information