Lion Cubs Club (Ages 4-7) Interest Form
Sometimes, a kid just needs to be a kid. Lions Cub Club gives children affected by epilepsy (either themselves or a loved one) an opportunity to meet other young people from the area, with trained volunteers and staff helping to create a safe environment where kids can connect and find common ground in the fight against epilepsy.
Campaign ID
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Child's Name
*
First Name
Last Name
Child's Date of Birth
*
/
Month
/
Day
Year
Date
Date of Epilepsy Diagnosis
/
Month
/
Day
Year
Please estimate if needed
Neurologist/Epileptiologist
*
Hospital Associated with
*
Please share with us: Your Child's Interests, Hobbies, Favorites and/or Recent Accomplishments
*
Please List Siblings Names and Ages
What types of Support is needed for your Child with Epilepsy and/or siblings?
*
Parent Name
*
First Name
Last Name
Parent E-Mail
*
example@example.com
Parent Mobile Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information and/or Comments
Please verify that you are human
*
Submit Application
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