Name: Teen Connect Group
Start: 2024-08-13T18:30:00-05:00
End: 2024-08-13T19:30:00-05:00
Location: Virtual Event via Zoom Meeting

First Name

Last Name

Phone

Preferred Contact Method

EmailPhoneText

Date of Birth

Sign me up for EFMN's monthly e-newsletter!

Street Address

City

State

Zip Code

5-Digit Zip Code Calculation

What is your primary relationship to 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 statements below and select the one that applies.

I consent to receive SMS text communications from the Epilepsy Foundation of Minnesota (EFMN) at the phone number provided above. I understand that messaging frequency may vary, and message & data rates may apply. Reply STOP to opt out of SMS text messages at any time.I do not consent to receive SMS text communications from the Epilepsy Foundation of Minnesota at the phone number provided above.

Emergency Contact

We are collecting Emergency Contact information for these events. Should a seizure or other medical situation arise for you during the group time, we need to have access to an emergency contact, and your physical location address. This information is not shared outside of EFMN staff unless they need to contact EMS services to respond to your home to provide medical care.

First Name

Last Name

Relationship

Phone

Email Address

Teen Connect Group

August 13 @ 6:30 pm - 7:30 pm

Details

Venue

RSVP

Teen Connect Group 08/13/2024