Survey

Welcome to the "Women & Epilepsy Across the Lifespan" Online Registration Form! Please enter your information on the form below to register for the workshop.

If, for any reason, you need to cancel your registration, please call Bill at (907) 561-3701 or email billp@stonesoupgroup.org.

Online Registration: Women & Epilepsy Across the Lifespan

Tuesday, July 20, 2010

9:00am to 3:30pm

at the BP Energy Center (1014 Energy Ct - Anchorage)

Click here for directions/map: Find us!

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1. Participant's Info:

Participant's Info: Name:
Organization:
Address:

City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

2. I am interested in this event because (check all that apply):

I am interested in this event because (check all that apply): I have epilepsy or a seizure disorder.

I have a daughter or son with epilepsy or a seizure disorder.

I have another family member or relative with epilepsy/seizure disorder.

I have a client or patient with epilepsy/seizure disorder.

I am employed by a State of Alaska health agency.

I am a service provider.

I am a medical provider.

I am a school nurse.

I provide support and/or advocacy on behalf of persons or families.

Other (please specify)

*1. Participant's Info:

2. I am interested in this event because (check all that apply):

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1. Participant's Info: