Seizure Smart Training Video Request Form

Please complete the form below and select the requested training video. You will be redirected to your selected training video upon submission. You will also receive an email with the link to the training.

Contact Information

First Name

Last Name

Phone

Zip Code

State

Additional Information

Organization/Employer

If none, please leave blank.

Industry Type

Please specify:

Is this your work email?

Email listed above

Work Email

Demographic Information

Date of Birth

Gender

MaleFemaleNon-binaryPrefer to Self-DescribePrefer not to answer

Please describe:

Pronouns (Optional)

Race

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMixed RacePrefer not to answer

Ethnicity

Hispanic, Latinx or Spanish OriginNot Hispanic, Latinx or Spanish OriginPrefer not to answer

What is your primary relationship to epilepsy?

Has Epilepsy (Self)Another Family Member Has EpilepsyChild Has EpilepsyFriend/Co-Worker Has EpilepsyLost Someone with EpilepsyParent Has EpilepsySpouse or Partner Has EpilepsyWorks with People with EpilepsyOther / Prefer Not to Answer

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.

Training Information

How did you hear about this training?

Staff Member Name

How many individuals will be viewing this video?

Would you like a Certificate of Completion?

YesNo

Video Requested

Video Request Link

Unsure which training to choose? Click here to read more about each training.

Please read the statements below and select the one that applies.

I consent to receive SMS text communications from the Epilepsy Foundation of Minnesota (EFMN) at the phone number provided above. I understand that messaging frequency may vary, and message & data rates may apply. Reply STOP to opt out of SMS text messages at any time.I do not consent to receive SMS text communications from the Epilepsy Foundation of Minnesota at the phone number provided above.

Contact Information