Purple Camp Interest Form
Operated by Epilepsy Foundation New England, The Purple Camp offers children and their families a friendly and safe environment to experience being at camp and the opportunity to make new friends.
Camper's Name
*
First Name
Last Name
Camper's Date of Birth
*
/
Month
/
Day
Year
Date
Neurologist/Epileptiologist
*
Hospital Associated with
*
Parent Name
*
First Name
Last Name
Parent E-Mail
*
example@example.com
Parent Mobile Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information and/or Comments
Please verify that you are human
*
Submit Application
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