Home Forms Advocacy Champion Application Advocacy Champion Application Current Start Your Profile More Information Complete Start First Name Last Name Email Phone or Mobile Phone Date of Birth City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code To which gender identity do you most identify? Optional - None -ManWomanGender non-conformingNon-binaryGenderqueerTrans ManTrans WomanDon’t knowPrefer not to answerPrefer to self-describe self-describe below Optional What is your ethnicity? Optional - None -Hispanic, Latinx or Spanish OriginNot Hispanic, Latinx or Spanish OriginPrefer not to answer self-describe below Optional What is your race? (check all that may apply) Optional American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Prefer not to answer Unknown Other/Prefer to self-describe self-describe below Optional Find an Epilepsy Specialist Ready for help? Find an Epilepsy specialist who can help guide you through your epilepsy journey. Find a Doctor Near You
