Name: EFMN In Person Connect Group
Start: 2025-09-02T18:00:00-05:00
End: 2025-09-02T19:30:00-05:00
Location: FM Area Foundation

Disclaimer: HIPAA (Health Insurance Portability and Accountability Act) sets standards for protecting the privacy and security of health information. This registration form is not HIPAA compliant and should not be used to submit protected health information (PHI).

Who are you registering for?

MyselfMyself and Someone Else

Your Information

Please provide your information below. If you are registering any additional attendees, you will add their information later.

First Name

Last Name

Email Address

Phone Number

Preferred Contact Method

EmailPhoneText

What is your Primary Relationship to Epilepsy?

Emergency Contact

We are collecting Emergency Contact information for these events. Should a seizure or other medical situation arise for you during the group time, we need to have access to an emergency contact, and your physical location address. This information is not shared outside of EFMN staff unless they need to contact EMS services to respond to your home to provide medical care.

Emergency Contact Full Name

Emergency Contact Phone Number

Emergency Contact Relationship

Have you participated in an EFMN Social Event this year?

YesNo

Please list the date of the most recent EFMN Social Event you attended.

Additional Information

These questions help EFMN ensure we are reaching everyone in our community and help us to receive grants to fund our programming. Thank you!

Street Address

Please include Apt #, Unit #, etc. when applicable.

City

State

Zip Code

Date of Birth

Gender

Pronouns (Optional)

example: she/her

Race

Ethnicity

Who else will you be registering for? Select all that apply.

Household member(s)Non-Household member(s)

Dietary and Accessibility Needs

Do you or any of your guests have dietary restrictions or allergies? If yes, please describe.

Do you or any of your guests have mobility needs that we should be aware of?
If yes, please describe.

EFMN has some funds available to help guests attend our programs and events. Would you like to request financial assistance for this event?

Yes, I am in need of financial assistance.No, not at this time.

Please read the statement below and check the box in agreement.

I understand that events hosted by the Epilepsy Foundation of Minnesota are voluntary and EFMN and EFMN staff members are not responsible for the participant's overall health and safety.

EFMN In Person Connect Group

September 2 @ 6:00 pm - 7:30 pm

RSVP