EFAZ Share Your Story Project

20 Apr

By Epilepsy Arizona

EFAZ Share Your Story Project

April 20, 2017 | By Epilepsy Arizona |

If you have epilepsy, are the parent/guardian, sibling, or friend of someone w/epilepsy and want to share your story to help inspire others, please carefully read and complete the following form. Thank you!

Requirements NOTE: ALL participants MUST read/complete the following release form in order to have their responses considered by the Epilepsy Foundation of Arizona. Thank you!
Epilepsy Foundation of Arizona: Share Your Story - RELEASE FORM *
AUTHORIZATION AND RELEASE TO USE LIKENESS: I grant the Released Parties (Epilepsy Foundation of Arizona) the right to photograph and/or videotape me and/or my child or ward and further to display, use and/or otherwise exploit my and/or my child’s or ward’s name, face, likeness, voice, and appearance forever and throughout the world, in all media, whether now known or hereafter devised (including, without limitation, in online webcasts, television, motion pictures, films, newspapers, and magazines) and in all forms including, without limitation, digitized images, whether for advertising, publicity, or promotional purposes, including, without limitation, publication of Event results and standings, without compensation, reservation or limitation. This Waiver, Release, Promise not to Sue, Authorization and Release to Use Likeness Form shall be governed by the laws of the State of Arizona. I certify I am eighteen (18) years of age or older and, if I am executing this Waiver and Permission Form on behalf of my child or ward, the information set forth pertaining to my child or ward is true and complete. I HAVE READ, UNDERSTOOD AND ACCEPT THE CONDITIONS OF THIS (i) LIABILITY RELEASE, INDEMNITY, AND PROMISE NOT TO SUE, AND (ii) AUTHORIZATION AND RELEASE TO USE LIKENESS.Yes, I understand & agree to the terms.
Is the participant 18 years or older? *
If not, please type in the legal parent/guardian name below NOT the child's name.Yes, the participant is over 18.No, the participant is under 18 & I am their legal parent/guardian.
Type in e-signature of participant (if over 18 years of age) or parent or court appointed guardian (if participant is under 18 years of age):
First Name *
Last Name *
Date *
Email *
Do you have epilepsy or a seizure-related condition? *
PLEASE SELECT ONEYes, I have epilepsy.No, I am the parent/guardian of someone w/epilepsy.No, I am the sibling/friend of someone w/epilepsy.

Please provide a response to the following questions below:

These questions apply to individuals w/epilepsy as well as parents/guardians, siblings, and friends of individuals w/epilepsy.

1. When was your (their) first seizure and was the cause behind it apparent/known? *

2. If you could describe what it’s like having epilepsy and/or a seizure-related disease (or being the parent/guardian of someone who has epilepsy) in 5 words or less, what would they be? *

3. How did you feel when you found out about your (their) diagnosis? What would you tell others going through a similar process? *

4. What is your reaction to the term “invisible disability” as it relates to epilepsy and/or a seizure-related disease? *

5. In what ways has epilepsy/seizures impacted your life? *

(As either a person with epilepsy or a parent/guardian of someone with epilepsy)

6. How has epilepsy or your seizures strengthened you? *

(As either a person with epilepsy or a parent/guardian of someone with epilepsy)

7. What is your biggest hope for the future as it relates to having epilepsy or a seizure-related disease (or being the parent/guardian of someone who has epilepsy)? *

8. How has the Epilepsy Foundation of Arizona helped you? *

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20 Apr

EFAZ Share Your Story Project

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