YLN Registration Form
Welcome to the Young Leaders Network (YLN). Youth will be working with Chanda Gunn, Field Service Managers, and AmeriCorps members on projects they are interested in. Please take a few minutes to complete the form below so that we may get to know your child, ensure their safety and privacy and create a positive community within YLN! Please complete the following in its entirety.
Participant's Name
*
What do you want me to call you?
Participant's Cell Phone #
Participant's Email
example@example.com
Participant's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name
School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you live at home or school?
Home
School
Other
Participant's Facebook
Participant's Instagram
Participant's Twitter
Parent/Guardian
First Name
Last Name
Cell Phone #
-
Area Code
Phone Number
Home Phone #
Email Address
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
Relationship
Cell Phone #
Doctor's Name and Medical Facility
Doctor's Phone Number
-
Area Code
Phone Number
Please give transportation details for the participant attending the meetings.
Type of Seizure
This seizures action plan will be kept confidential among staff and trained volunteers.
Please describe the seizures and what they look like and any identifying characteristics.
This seizures action plan will be kept confidential among staff and trained volunteers.
Emergency Protocol
Is there anything specific that might be a seizure trigger? (photosensitivity, heat, anxiety, etc.)
Does your child have any dietary restrictions?
Please Select
yes
no
If yes, please describe the dietary restrictions which they adhere to.
Does your child have any allergies?
Please Select
yes
no
If your child has allergies, please describe and include the reactions, symptoms and treatment.
Participant’s hobbies and interest include:
How did you hear about the Epilepsy Foundation New England?
School
Website
Social Media
Doctor
Other
Please share what you feel is important for your child to take away from the YLN meetings.
Please explain what your child's expectations and goals are from the YLN meetings.
Is there anything else you would like to share about your child in order to help your participant be more successful?
Submit
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