Registration Form:
Please fill out the following to participate in the Epilepsy Wellness Series: The Preteen Education Series.

The Preteen Education Series is an interactive social media program that will run for 8 weeks and cover the following topics: Emotional Health, Diet and Nutrition, Physical activity, Sleep, Independent living, Stress Management, Social Relationships, and Education. Participants, along with their parents, will learn about each topic and way to create healthy habits.

The goal is to encourage kids to take an active role in their health and epilepsy management. Learning these skills can help them overcome challenges they may face currently and in the future.

Email address *
Participants Name *
Participants Age *
Participants Address *
Parent's Phone Number *
In order for your child to participate, you as the parent must have a Facebook account. Parents are responsible for monitoring all information posted online on behalf of the child this included anything written and any photos or videos you choose to post. All communication for Epilepsy Wellness Series: Preteen Education will take place in a private group and activity will be monitored by EAL. You agree not to share any information outside of this group.
Parent's Name
Do you agree to the consent above? *
Today's Date: *
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