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Donation Form

Your donation helps to educate the community about epilepsy and provide services to people living with epilepsy, their families, and their loved ones. Please make a contribution today!

Donation Form

1. First Name *
   
2. Middle Name
   
3. Last Name *
   
4. Donation Type General Donation Awareness Bracelet Memorial Honorarium *
   
5. Address *
   
6. Address 2
   
7. City *
   
8. State Alaska Alabama Arkansas Arizona California Colorado Connecticut District Of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming *
   
9. Zip Code *
   
10. Country Ascension Island Andorra United Arab Emirates Afghanistan Antigua and Barbuda Anguilla Albania Armenia Netherland Antilles Angola Antarctica Argentina American Samoa Austria Australia Aruba Azerbaidjan Bosnia-Herzegovina Barbados Bangladesh Belgium Burkina Faso Bulgaria Bahrain Burundi Benin Bermuda Brunei Darussalam Bolivia Brazil Bahamas Buthan Bouvet Island Botswana Belarus Belize Canada Cocos (Keeling) Islands Congo, The Democratic Republic of the Central African Rep. Congo, Republic of Switzerland Ivory Coast Cook Islands Chile Cameroon China Colombia Costa Rica Serbia and Montenegro Cuba Cape Verde Christmas Island Cyprus Czech Republic Germany Djibouti Denmark Dominica Dominican Republic Algeria Ecuador Estonia Egypt Western Sahara Eritrea Spain Ethiopia Finland Fiji Falkland Islands (Malvinas) Micronesia Faroe Islands France Gabon Great Britain (UK) Grenada Georgia Guyana (Fr.) Guernsey Ghana Gibraltar Greenland Gambia Guinea Guadeloupe (Fr.) Equatorial Guinea Greece South Georgia and the South Sandwich Islands Guatemala Guam (US) Guinea Bissau Guyana Hong Kong Heard and McDonald Islands Honduras Croatia Haiti Hungary Indonesia Ireland Israel Isle of Man India British Indian O. Terr. Iraq Iran Iceland Italy Jamaica Jordan Japan Kenya Kirgistan Cambodia Kiribati Comoros SaintKitts Nevis Anguilla Korea (North) Korea (South) Kuwait Cayman Islands Kazachstan Laos Lebanon Saint Lucia Liechtenstein Sri Lanka Liberia Lesotho Lithuania Luxembourg Latvia Libya Morocco Monaco Moldavia Madagascar Marshall Islands Macedonia, The Former Yugoslav Republic of Mali Myanmar Mongolia Macau Northern Mariana Islands Martinique (Fr.) Mauritania Montserrat Malta Mauritius Maldives Malawi Mexico Malaysia Mozambique Namibia New Caledonia (Fr.) Niger Norfolk Island Nigeria Nicaragua Netherlands Norway Nepal Nauru Niue New Zealand Oman Panama Peru Polynesia (Fr.) Papua New Guinea Philippines Pakistan Poland Saint Pierre and Miquelon Pitcairn Puerto Rico (US) Portugal Palau Paraguay Qatar Reunion (Fr.) Romania Russian Federation Rwanda Saudi Arabia Solomon Islands Seychelles Sudan Sweden Singapore Saint Helena Slovenia Svalbard and Jan Mayen Islands Slovak Republic Sierra Leone San Marino Senegal Somalia Suriname Saint Tome and Principe El Salvador Syria Swaziland Turks and Caicos Islands Chad French Southern Territories Togo Thailand Tadjikistan Tokelau Turkmenistan Tunisia Tonga East Timor Turkey Trinidad and Tobago Tuvalu Taiwan Tanzania Ukraine Uganda United Kingdom US Minor outlying Islands United States Uruguay Uzbekistan Vatican City State SaintVincent and Grenadines Venezuela Virgin Islands (British) Virgin Islands (US) Vietnam Vanuatu Wallis and Futuna Islands Samoa Yemen Yugoslavia South Africa Zambia Zaire Zimbabwe *
    
11. Phone Number *
    
12. Email Address *
    
13. Confirm Email *
    
14. Interests

    Women and Epilepsy	Seniors and Epilepsy	Clinical Trials
    Referrals	Children and Youth	Employment
    Advances in Treatment	Scholarships	Men and Epilepsy
    Driving/Transportation	Volunteer Opportunities

15. Is this in response to our annual appeal?
    YesNo *
    
16. If so, do you want to designate 10% of your donation to college/camp scholarships?
    YesNo *
    
17. Number of packs *
    
18. Additional donation $
    
19. Next of Kin/Honoree
    
20. Address
    
21. Honoree
    
22. Address
    
23. Donation Amount $ *
    

Required fields are marked with an asterisk (*)

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919 Walnut Street, Suite 700 • Philadelphia, PA 19107-5237 • Phone: 215-629-5003 or 800-887-7165 • Fax: 215-629-4997
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