Adult Envoy Interest Form

Envoy Interest-Adult

Become an Envoy - be empowered to share your experiences and educate lawmakers to help advance Epilepsy Foundation New England's policy priorities. An envoy will establish an ongoing relationship with their legislators and participate in advocacy activities throughout the year. Our Epilepsy Envoy (E2) program is designed to empower and strengthen your voice by sharing your story to inform others about epilepsy.
Please Note: This form is for expressing interest in becoming an Envoy for EFNE. Envoys are volunteers and must reside in Maine, Massachusetts, New Hampshire, Rhode Island, or Vermont.

If you are looking for support for yourself or a loved one with epilepsy, please call 617-506-6041.
Name

First NameLast Name
Campaign ID
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Source
E-Mail
example@example.com
Mobile Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Epilepsy Connection
Additional Information and/or Comments
Type a question
Should be Empty:

Envoy Interest-Adult