EPILEPSY WELLNESS: Uplift Enrollment Form

Epilepsy Wellness Program Enrollment Form: Uplift for Emotion Regulation

Please complete this form to register for the Uplift for Emotion Regulation online course.
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Adults (18+) Only
In which Epilepsy Wellness program would you like to enroll?*
Select one. If you would like to enroll in multiple Epilepsy Wellness programs, please submit one enrollment form per program or contact us via email for assistance.
E-mail Address*
Phone #*

Area CodePhone Number
Physical Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Why are you interested in enrolling in this Epilepsy Wellness program?

I have epilepsyA friend or family member has epilepsyGeneral interestProfessional interest as a healthcare workerOther
Do you currently live in Texas?*
Race / Ethnicity
Gender
Please review the following information:
- This course is scheduled to begin on April 21st, 2021 for all participants, and will consist of a one-hour live class each Wednesday, for an 8-week period.
- We are accepting enrollment of a maximum of 10 people into this course.
- Please ensure you are able to attend all or the majority of the eight classes prior to submitting this enrollment form.
Select a START DATE and choose a corresponding time slot. The time slot you select will be the time of your class for each session of this eight week course. *
Can you commit to attending all eight Uplift live classes as scheduled?

YesNoOther
You will receive a phone call from an Epilepsy Wellness representative shortly after submitting this form; during this call we will verify your enrollment and review some basic program information. Do you have any specific questions or concerns you would like to be sure and review on that call? *
Should be Empty:

Epilepsy Wellness Program Enrollment Form: Uplift for Emotion Regulation