Registration Form for Monthly Meet Up (MMU)

If you’re aged 18-24 and living with epilepsy, why not join us for our Monthly Meet-Up (MMU)?

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1. What is your name (first name and surname). (Required.)

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2. Please enter your contact number (Required.)

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3. Please enter your email address (Required.)

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4. This group is for young adults with epilepsy, aged 18-24  years.
What age are you? (Required.)

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5. What county do you live in? (Required.)

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6. Have you previously linked in with your local Community Resource Officer? (Required.)

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7. What age were you when you were diagnosed with epilepsy? (Required.)

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8. How would you rate your knowledge of your diagnosis/epilepsy?
0 = I have no knowledge 
10 = I have all the knowledge I need (Required.)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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9. How easy is it for you to meet other young people living with epilepsy?
0 = I have not met any other young people with epilepsy 
10 = I find it very easy to meet other young people with epilepsy (Required.)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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10. Why are you interested in participating in this group? (Required.)

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11. How does your epilepsy impact your day-to-day life
0 = Does not impact my life in any way
10 = Impacts my life on a day-to-day basis (Required.)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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12. Do you feel that you have missed out on activities/events due to your epilepsy? (Required.)

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13. What are the main issues that concern you as a young person living with epilepsy? Or - are there any topics you would like to see addressed during the sessions (e.g. mental health/wellbeing, memory/study/exams etc.) (Required.)

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14. How comfortable are you in telling people outside your family/friend group about your Epilepsy?
0 = Extremely Uncomfortable
10 = Extremely Comfortable (Required.)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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15. What are the three things you are hoping to get from participating in this group? (Required.)

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16. Thank you for taking the time to answer these questions. It will allow us to plan, prepare and evaluate our work. 

Have you any questions for us?

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