Hope the Lion Plushies Request Form:
Hope reminds everyone that where there is a person living with epilepsy, there is Hope. Lions represent courage, strength and pride. Hope the Lion is free for people living with epilepsy in MA, NH, ME & RI.
Please know that if you live out of our service area (Massachusetts, New Hampshire, Maine or Rhode Island) or you have requested a plushy for someone who does not have epilepsy there will be a $35 cost for a Hope the Lion package. https://www.classy.org/event/hope-the-lion/e268982
Does Recipient Have Epilepsy?
*
Yes
No
Do you live in MA, NH, ME, RI, or VT
*
Yes
No
EFNE provides one Hope Lion to everyone living with epilepsy in our area of service( MA,NH, ME, RI and VT). If you live outside of our service area you can purchase a Hope Lion for $35. Would you like to purchase one?
Yes
No
Campaign ID
Who is the recipient of Hope the Lion?
*
Child
Self
Other
Hope Lion Recipients Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Recipient's Mobile Number
*
Format: (000) 000-0000.
Recipient's E-mail
*
example@example.com
Recipient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Epileptologist/Neurologist:
Hospital Affiliated with:
If requesting Hope Lion for your child please tell us your name:
First Name
Last Name
Parent/Caregiver Email:
example@example.com
Parent/ Caregiver Mobile Number:
Please enter a valid phone number.
Format: (000) 000-0000.
If requesting Hope Lion for someone please tell us your name:
First Name
Last Name
Your Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
What is your relationship to the recipient of Hope the Lion:
Parent
Grandparent
Friend
Doctor
Nurse
CHW
Social Worker
Other
How did you hear about Hope?
*
Please Select
Friend
Website
Facebook
Instagram
Health Care Provider
Teacher or Educator
Epilepsy Foundation New England
Other
Any additional information you would like to give us:
Submit
Should be Empty: