Request Seizure Smart Childcare Personnel Training Recording

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Last Name

Email

Phone

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How many individuals will be viewing this recording?

What is your relationship to epilepsy?

I have epilepsy/seizuresMy child has epilepsy/seizuresMy parent has epilepsy/seizuresMy spouse or partner has epilepsy/seizuresAnother family member has epilepsy/seizuresI lost someone who had epilepsyA friend/co-worker has epilepsy/seizuresI work with people who have epilepsy/seizuresOther/prefer not to respond

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Demographic Information

EFMN is asking demographic questions to have a better understanding on who we serve. Although all questions are required, there is always a "Prefer not to answer" option if you choose to keep this information private.

The options for demographic questions are in accordance to the US Census Bureau.

Gender

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Staff Member Name