Epilepsy Wellness: Program Interest Form
Please fill out this form to be placed on a rolling waitlist for enrollment into an Epilepsy Wellness School. When new sessions of the program you select below become available, one of our representatives will reach out to assess your continued interest in enrolling at that time. We are working to grow our resources and staffing in order to better support the community with additional program offerings. Thank you for your interest in epilepsy wellness, and we hope to work with you soon!
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
All course participants must be 18 years of age and older.
Phone Number
*
Providing a cell phone number is recommended.
Email
*
example@example.com
I would like more info about ;
*
Epilepsy Wellness School
Other
Do you have any additional comments / information you would like to submit to our staff at this time?
Submit
Should be Empty: