Application for Epilepsy Foundation of Southeast Wisconsin: Youth Council

Contact Information

Name: Age:

Address:

City:

State:

Zip:

Phone:

Alternate Phone:

Email:

Questions and Interests What interests you about the Youth Council?:

Do you or someone you know have epilepsy?:

If you could tell someone one thing about living with epilepsy, what would it be?:

If chosen for the council, what is one goal you would like to see achieved by the members?

If not chosen for the council, are interested in becoming a youth volunteer?:

What would you like us to know about you? Example: Your interests, personality, hobbies, accomplishments and so forth.

Availability

Please fill out the following availability schedule: Please put a check in the box if you are available or use the "Enter your own" to list the available time slot you have for that day.

Day	8am to noon	Noon to 4	4pm to 8pm	Enter Your Own
Sunday
Monday
Tuesady
Wednesday
Thursday
Friday
Saturday

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