Become a Member

Complete the application form below, or download a PDF of the registration form.

Organization Name

Tax ID

Organization is a registered 501c(3)

Address Line 1

Address Line 2

State

Zip Code

Executive Director Name

Phone Number

Email Address

Organization Website URL

In applying to become a Member Organization of Epilepsy Alliance America, the above-name organization, confirms that it meets the following criteria:

Activities and goals of the organization are focused on supporting people affected by epilepsy and/or seizure disorders;
The organization is formally organized with a written constitution and/or Bylaws as a 501c3 organization;
The organization has a Constitution and/or Bylaws which do not conflict with that of the Epilepsy Alliance America.

Authorized Official Name (First & Last)

Authorized Official Signature (Please Initial)

Authorized Official Title

Please leave this field empty. Please leave this field empty.

BECOME A MEMBER