Hello!
We are creating a dating website specifically for people impacted by epilepsy including caregivers and friends and families. If you are interested in being one of the first to join the website please complete all fields in the form below.
First Name is required.
Email is required.
Do you have epilepsy?
Yes
No
Age Range
Younger than 18
18 to 24
25 to 30
31 to 36
37 to 45
46 to 50
51 to 56
57 to 65
65+
Male
Female
Other
PRE-REGISTER