Thank you for your interest in volunteering for our new peer support program. This new program will launch in approximately March of 2021. By providing us with your information below, we'll add you to our waiting list for more information on the application process and training. If you are a parent, you must be at least one year out from your child's most recent epilepsy surgery.  

Thank you!

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your email address?

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* 4. What is your phone number?

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* 5. What is your mailing address?

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* 6. Which best describes you?

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* 7. I speak the following languages:

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