To become a member of the Edmonton Epilepsy Association, complete the form, below, please enter in your information with the following format:

Name: Enter your AGENCY’s NAME
Contact Person: Enter your full name.
Address: Enter your street address (eg: 1234 – 45 Ave SW) in the first box. In the following box enter your City, Province, Postal Code (please use a comma to separate them)
Email: enter your Email address (this is where we’ll send your sign in info and receipt)
Phone: enter your phone number. (The phone your normally use)