This year for National Epilepsy Awareness Month, we are introducing a new social media campaign called, “Epilepsy Does Not Define Me.” Similar to our previous campaign, “Faces of Epilepsy,” we hope to use our platform this month to showcase the strength of our community, in a new and creative way. We are asking our community members who are epilepsy warriors themselves to fill out this survey if you are interested in being featured in our upcoming social media campaign. If you have any questions, please reach out to our Communications Manager Zoe Heller at zheller@efepa.org. Thank you!

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* 1. First and Last Name:

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* 2. Your Pronouns (ex: she/her, he/him, they/them, ze/hir)

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* 3. Your Phone Number:

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* 4. Email Address:

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* 5. Your personal roles (ex: teacher, father, mother, sister, cousin, police officer, daughter, nurse, etc.):

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* 6. Your hobbies/activities/interests (ex: cheerleader, comic book enthusiast, cat lover, soccer player, crocheter, writer, violin player, etc.):

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* 7. OPTIONAL: Tell us a little bit about yourself and your story (200 word max):

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* 8. OPTIONAL: How did you get connected to the EFEPA? (100 words max) 

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* 9. Please upload a high-resolution JPEG or PNG photo of yourself, preferably a close-up headshot or selfie.

PNG, JPG, JPEG file types only.
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