Walk for Epilepsy : Register

Joining Team Queensland Survivors

First Name *

Last Name *

Email Address *

Password*

Phone *

Date of birth *

Gender *

Male Female Other

Are you happy to receive occasional emails from us about our services and fundraising?

Yes No

(enter manually)

UnitStreet Number *

Street *

Town/Suburb *

Postcode *

State *

Country *

Why are you taking part in the Walk for Epilepsy? *

How did you hear about the event?

Are you willing to share your story? *

Yes
No

Have you used our services? If so, which one(s)?

Please confirm what size you are for merchandise: *

I agree to Walk for Epilepsy's terms and conditions. *