ESEBC Purple Day Volunteer Form Name Name First First Last Last Phone Email If you have any physical limitations, please state below: Emergency Contact Information Emergency Contact Information First/Last First/Last Phone Number Phone Number I am under 18 years of age and require parent/legal guardian consent to volunteer. * Yes No “I, confirm that the information in this volunteer application is complete and true. I understand and agree that any omission or misrepresentation with respect to the information given may be cause for refusal of the volunteer application.” I understand, and give permission for the Center for Epilepsy to keep record of my personal information and that it will remain confidential. I understand that this information may be disclosed to any party with legal and proper interest, and I release the agency from any liability whatsoever for supplying such information." * Yes, I confirm No If you are human, leave this field blank. Submit Δ
