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Epilepsy Foundation Mississippi Community Awareness Day Registration
Please fill out this form. For additional questions, please contact us: mississippi@efa.org
6
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1
Parent/ Guardian Name
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Parent/ Guardian Names
First Names of Parents/ Guardians Attending
Last Name
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2
Child's Names and Ages
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Please enter all children's names and ages attending.
Child's Full Name(s)
Age(s)
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3
Phone Number
*
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Please enter a valid phone number.
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4
Email
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example@example.com
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5
Please read the General Release and Waiver of Liability and sign electronically by clicking "next" to advance to the next question.
To open the file, right click and select "open image in another tab."
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6
Signature
*
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Please type your name below to acknowledge and represent that you have carefully read and understand all terms of this Release and Waiver of Liability.
Parent Name
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