Be Heard Application

Name
Date of Birth
Address:
City:
Province:
Postal Code:
Telephone
E-Mail:

Types of seizures:
Tonic-Clonic
Absence
Complex Partial
Simple Partial
Nocturnal
Other

Frequency of seizures:
Daily
Weekly
Monthly
Controlled

Age of first seizure:


Where did you hear about the Epilepsy Youth Challenge?
Local Agency
Radio
Newspaper
School
Other


Tell us a bit about YOUR epilepsy experience:


If there was one thing you wish people understood about epilepsy and seizures, what would it be?


Do you think that it's possible to change people's attitudes about epilepsy? What would it take?


What are your future goals?