Name: Open Gym Family Connect
Start: 2024-11-19T17:30:00-06:00
End: 2024-11-19T18:30:00-06:00
Location: Explorer Academy

First Name

Last Name

Phone

Preferred Contact Method

EmailPhoneText

Date of Birth

How many guest(s) will be attending the activity with you?

List name(s) and age(s) of guest(s) attending with you.

Do you or your guest(s) have mobility needs we should be aware of?

YesNo

If yes, please explain.

Street Address

City

State

Zip Code

5-Digit Zip Code Calculation

What is your primary relationship to epilepsy?

What is your child's full name?

What is your child's birthdate?

What is your parent's full name?

What is your spouse/partner's full name?

Which family member has epilepsy?

Gender

Race

Ethnicity

*Why are you asking these questions?

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.

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.

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.

Open Gym Family Connect

November 19, 2024 @ 5:30 pm - 6:30 pm

RSVP