Adolescent ECD submittal form logo

This graphic was graciously designed and donated by Sam De Clercq to the Adolescent Epilepsy Contact Database (AECD). Sam is from Belgium, and is very instrumental in the maintenance of the AECD.

The purpose of the form below is common communication between adolescents younger than 20 years of age who have epilepsy. This forum has been set up as the next stage of the Epilepsy Contact Database and was created to follow our children as they grow up. This forum is for them so they can share experiences, frustrations, and concerns with each other. It is difficult to find someone who can truly relate. Who is there to sympathize with?

The form below will enter you into a database of common characteristics. Once entered, you will be e-mailed the database's private Web site address that will allow you access to those participating in all three databases. This Web site address is made available only to the database participants. Contact these people, comfort them and be comforted. Having a child with epilepsy can be a lonely life.

When done, click on "Submit." This information will be shared only with those people that participate in this program.

Your first name: Last name:

Your age:

Seizure type: Seizure frequency: (e.g. 3/month)

Medication(s) being taken:

Your state of health:

E-mail address:

To ensure accuracy, please type your email address again. It is required for entry into the database.

E-mail address: State or country (optional): (e.g. Canada)

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