Consumer Online Application

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Application for Assistance

The Jeanne A. Carpenter Epilepsy Legal Defense Fund will review submitted cases to see if we can help with legal information or with finding a lawyer to assist you.

Title:
*First Name:
*Last Name:
*Address 1:
Address 2:
*City/Province:
State (if US):
*Zip/Postal Code:
Country:
*Email:
Home Phone:
Work Phone:
Referral Source:
Attorney Affiliate Website/Internet
Media Relative  
Best Way to Contact You:
Case Description:
Criminal
  Arrest
  Prison Conditions or denial of medical care
Education
  Elementary or secondary school
    public school
    private or parochial school
  Post secondary institution
    public
    private or parochial school
Employment
  Filed Complaint with Equal Employment Opportunity Commission (EEOC) or state agency
  Received Right to Sue Letter from EEOC or state agency
  Union Member
  Federal Employment
Child Custody
Driving
  Personal
  Commercial
Professional License/Certification Type (e.g. Firefighter or Medical)
Government Assistance (SSI/SSDI, Veteran's Benefits, Medicare/Medicaid)
Immigration
Institutional Treatment
Insurance
Military
Public Accommodations (Alleged wrongdoer is a store, restaurant, or other place serving the public)
Personal Injury
 

Please provide us with a brief description of the facts of your case, including, if appropriate, contact information for your attorney. The description should indicate:

  • The specific type of discrimination or other illegal act(s) that you believe occurred, including how it was related to epilepsy;
  • The identity and location of any employer, school or other entity responsible for the act(s);
  • The date(s) on which the act(s) occurred;
  • Whether you have filed a complaint with a court or a state or federal agency (if so, identity the court or agency and the status of the complaint); and
  • For employment matters, whether the employer is a federal or state agency and whether you are a union member.
  • Also describe the type of seizures you experience, how frequently they occur, and the effect of the seizures (and anti-seizure medication you take) on your daily activities such as sleeping, mental concentration and the ability to work.

Please note that by submitting this information you are authorizing the Epilepsy Foundation, the Jeanne A. Carpenter Epilepsy Legal Defense Fund and its affiliated organizations and staff to disclose the necessary information to third party attorneys for the limited purpose of case review and selection, and understand that such disclosures will be kept confidential and protected by the attorney-client privilege in accordance with established ethics rules in your state.