Advocacy Interest
When it comes to advocating for those living with epilepsy, we mean business. That’s why we’re asking for your help to raise awareness and bring change to better support those living with seizures right here in our local communities. “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.”
Name
*
First Name
Last Name
Contact Source
*
E-Mail
*
example@example.com
Mobile Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your connection to Epilepsy
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I Have Epilepsy
My Parent Has Epilepsy
My Family Member Died of SUDEP
My Child Has Epilepsy
My Grandchild Has Epilepsy
Other SUDEP connection
My Sibling Has Epilepsy
My Family Member Has Epilepsy
I Work with or Educate those Affected by Epilepsy
My Partner Has Epilepsy
Advocacy Interest
*
Email my legislator
Call my legislator
Write to my legislator
Visit my legislator in district office
Visit my legislator at the State Capital
Speak with the Media about epilepsy
Write a letter to the media about epilepsy
Additional Information and/or Comments
Please verify that you are human
*
Submit Application
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