Envoy Interest-Adult
Become an Envoy - be empowered to share your experiences and educate lawmakers to help advance Epilepsy Foundation New England's policy priorities. An envoy will establish an ongoing relationship with their legislators and participate in advocacy activities throughout the year. Our Epilepsy Envoy (E2) program is designed to empower and strengthen your voice by sharing your story to inform others about epilepsy.
Name
*
First Name
Last Name
Birthdate
/
Month
/
Day
Year
Date
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
*
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
Additional Information and/or Comments
Please verify that you are human
*
Submit Application
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