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.*

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.
I am glad to share photo(s)
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HOW TO CONTACT ME

Name
Connection to Epilepsy
Address

MY STORY

ABOUT THE INDIVIDUAL WITH EPILEPSY

What is their name?