Our mission is to ensure that people with seizures are able to participate in all life experiences; and prevent, control and cure epilepsy through services, education, advocacy and research.
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Contact Information Form

Thank you for your interest in becoming involved with your local Epilepsy Foundation of Greater Los Angeles. Please complete the form below to enable us to communicate with you and help you stay informed about activities and information.
Contact Information
First Name
Last Name
Address
City, State Zip
Phone
Email
Please contact me by: Mail
E-Mail
Telephone
 
Yes, This is my first time contacting the local Epilepsy Foundation of Greater Los Angeles
 
How did you become aware of the Epilepsy Foundation of Greater Los Angeles?
Doctor A Friend / Relative Internet Media Flyer
Other, Please Specify
   
Connection to Epilepsy
To better serve you, it is helpful to know your connection to epilepsy, Please check the applicable box(es) below:
Teen with Epilepsy
Senior
Caregiver
Parent of a Teen with Epilepsy		 Adult with Epilepsy
Relative
Woman with Epilepsy
Spanish-speaking family with Epilepsy		 Parent of a Child w/ Epilepsy
Parent of an Adult w/ Epilepsy
Male with Epilepsy
Other, Please Specify
     
Epilepsy Nurse Specialist
General Neurologist
Pediatrician
Psychiatrist		 Nurse
Epilepsy Researcher
Pharmacist
Epileptologist-Neurologist 		School Staff
GP/Internist
Neurosurgeon
Psychologist
Other, Please Specify
   
Interests
I am particularly interested in:
Children's Issues
Senior/Elderly Issues
Employment
Volunteer Opportunities		 Education
Women's Issues
Research
Special Events/Community Events		 Male Issues
Latest News
Advocacy
Other, Please Specify
 
 

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