Epilepsy Foundation of Minnesota :: Shining Stars Form

Application Form

Child's Name (First, Last) *

Child's Birthdate (MM/DD/YY) *

Child's Gender *

Female

Male

Street Address *

City *

State *

Zip Code *

Parent's Name *

Phone *

Phone type *

Email *

Here are 4 things that make me (the child) wonderful: (This can be ANYTHING, your hobbies, something about yourself, things that make you special…) *

Upload a current photo (please be sure the photo title includes your child's name) *

You can use my photo in an upcoming newsletter & related EFMN materials! *

Yes

Upload a page that tells us more about you (the child), your seizures, things you would want others to know about you and your epilepsy. You can even draw a picture if you'd like! *

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