Share Your Story: Epilepsy
The Epilepsy Foundation is committed to involving people with epilepsy and their families and caregivers in the policymaking process. Share your story with us by filling out the form below.
First Name *
Last Name *
State *
Email address *
How old are you (or your child?) *
My epilepsy story fits is related to the following issue(s). Please check all that apply. *
What is your epilepsy story? Please highlight how your story relates to one or more of the following policy issue areas (research funding; epilepsy programs; Affordable Care Act; Medicaid; Medicare; CHIP; medical cannabis; access to prescription medications, devices, or surgery; disability; discrimination; and SUDEP ). *
Please upload a photo of yourself for our website (optional).
I hereby grant permission for the Epilepsy Foundation to use my story and photo on their websites and social media accounts. *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service