Name: Young Adult Connect Group
Start: 2024-09-05T18:30:00-05:00
End: 2024-09-05T19:30:00-05:00
Location: Virtual Event via Zoom Meeting

First Name

Last Name

Phone

Preferred Contact Method

EmailPhoneText

Date of Birth

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Street Address

City

State

Zip Code

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What is your primary relationship to epilepsy?

Gender

Race

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*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.

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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

Young Adult Connect Group

September 5 @ 6:30 pm - 7:30 pm

Details

Organizer

Venue

RSVP

Young Adult Connect Group 09/05/2024