Membership Registration Request

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

    CONTACT INFORMATION


    TAX INFORMATION


    Organization is a registered 501c(3)
    Please upload the previous (2) years of Form 990 (PDF)

    GENERAL INFORMATION


    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.