Sponsor a membership

    First Name (required)

    Last Name (required)

    Address

    Your Email (required)

    Name of sponsored individual

    Email of sponsored individual

    Date

    City

    State

    Zip

    Phone

    Chronic illness

    Cushings SyndromeOther Illness

    If other illness, please write here

    Family?

    Family member

    How did you hear about The EPIC Foundation

    Birthday

    This form is to sponsor a membership of $35

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