Request a visit from Brainstorm

** BRAINSTORM IS NOT CURRENTLY TRAVELING!

Oh boy! So you want me to come visit your house? I'm so excited to meet you! ~ Brainstorm the Bear

Please fill out the following request form. This information will only be given to the program director and the host family.

Note: An adult can request a visit for themselves as well! This program is intended to reach everyone with epilepsy or a seizure disorder. If you are an adult requesting a visit for yourself, please just make note of that in the "special comments" box at the bottom of the request form. Thanks!

** BRAINSTORM IS NOT CURRENTLY TRAVELING!

Parents/Guardian's Name

Child's Name

Child's Age

Diagnosis/Type of Seizures

Date of Diagnosis

Address

Address cont

City

State/Province

Zip/Postal Code

Country

Home Phone

E-mail address?