Name: Open Gym Family Connect
Start: 2024-09-24T17:30:00-05:00
End: 2024-09-24T18:30:00-05:00
Location: Explorer Academy 1780 17th St S Fargo, ND 58103

First Name

Last Name

Phone

Date of Birth

How many guest(s) will be attending the activity with you?

List name(s) and age(s) of guest(s) attending with you.

Do you or your guest(s) have dietary needs we should be aware of?

YesNo

If yes, please explain.

Do you or your guest(s) have mobility needs we should be aware of?

YesNo

If yes, please explain.

Street Address

City

State

Zip Code

5-Digit Zip Code Calculation

How do you prefer to pay for this event?

Pay in-person at the event (cash or check payments only)Pay online

Payment Information

Name on Card

Payment Amount

Card Number

Code

Billing Email

Billing Information

First Name

Last Name

Billing Street

Billing City

Billing State

Billing Zip

EFMN is committed to supporting all people who would like to attend our social events. If you need financial support, please check this box.

What is your relationship to epilepsy?

I have epilepsy/seizuresMy child has epilepsy/seizuresMy parent has epilepsy/seizuresMy spouse or partner has epilepsy/seizuresI lost someone who had epilepsy/seizuresAnother family member has epilepsy/seizuresA friend/co-worker has epilepsy/seizuresI work with people who have epilepsy/seizuresOther/prefer not to respond

What is your child's full name?

What is your child's birthdate?

What is your parent's full name?

What is your spouse/partner's full name?

Which family member has epilepsy?

Gender

Race

Ethnicity

*Why are you asking these questions?

EFMN is asking demographic questions to have a better understanding on who we serve. Although all questions are required, there is always a "Prefer not to answer" option if you choose to keep this information private.

The options for demographic questions are in accordance to the US Census Bureau.

Please read the statement below and check the box in agreement.

I understand that events hosted by the Epilepsy Foundation of Minnesota are voluntary and EFMN and EFMN staff members are not responsible for the participant's overall health and safety.

Open Gym Family Connect

September 24 @ 5:30 pm - 6:30 pm

RSVP