Share your Story - EE Website

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

SHARING MY STORY IN THE FIGHT TO END EPILEPSY

If you experience any challenges while completing this online form, need assistance or have any questions, please contact Lily Chan (lchan@epilepsylosangeles.org).

I want to share my story of epilepsy or my family's story to inspire and mobilize others.*

Yes No

THANK YOU! By indicating YES above, you are permitting the Epilepsy Foundation to share your story and completed information below (with the exception of personal contact information - phone, email, and mailing address) on our website, e-communication, social media platforms and at the discernment of the Epilepsy Foundation.

Yes, please tag me if and when you post my story on social media.

Yes No

Facebook Link

Twitter Handle

Instagram Name

I am glad to share photo(s)

Yes No

Upload and share a photo or video that is your motivation to be involved in the fight to End Epilepsy. No File Chosen

File uploads may not work on some mobile devices.

MY STORY

My Story in My Words

How does epilepsy affect your life / your child's life?

How does epilepsy affect your family more broadly?

Any particular experience or story you want to share about living with epilepsy to illustrate its effect on you?

ABOUT THE INDIVIDUAL WITH EPILEPSY

Who has epilepsy?

What is their name?

First Name

Last Name

How old are they now?

What age did the seizures start?

What is the type(s) of epilepsy/seizures?

SHARING MY STORY IN THE FIGHT TO END EPILEPSY

HOW TO CONTACT ME

MY STORY

ABOUT THE INDIVIDUAL WITH EPILEPSY