To request a Superstar Sibling Box for your child, simply fill out this request form. Superstar Sibling Boxes are free of charge, thanks in part to our generous Superstar Siblings sponsor, Marinus. Please allow 10-15 days for shipping.

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* 1. Superstar Sibling's Name

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* 2. Parent/Caregiver's Name

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* 4. Mailing Address

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* 5. Would you like to subscribe to the EFEPA eNewsletter?

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* 6. Would you like to receive information about our bi-monthly Parent Support Group?

The Superstar Sibling Program is made possible by contributions from donors and community partners. To help us maintain this funding, please complete this brief survey. You may also receive a follow up survey 1-2 months after your Superstar Sibling Box arrives.

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* 7. About Your Superstar Sibling

  Never Seldom Occasionally Frequently Always
My child worries about their sibling with epilepsy.
My child is embarrassed, saddened, or angry about others' reactions to their sibling's diagnosis.
My child feels a sense of responsibility for taking care of and/or protecting their sibling with epilepsy.
My child displays behavior that could be a potential sign of struggling emotionally. (ie: Anxiety, Mood Swings, Acting Out, etc.)
My child has tools, strategies, and/or resources they feel comfortable using when they are struggling emotionally.
My child is comfortable talking about their sibling's epilepsy.

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* 8. About My Superstar Sibling's Caretakers

  Never Seldom Occasionally Frequently Always
I/We feel comfortable talking to our child(ren) about their sibling's diagnosis.
I/We are able to recognize when our child(ren) are struggling emotionally.
I/We feel as though our family has a strong support system, both within and outside of the household.
As a caretaker, I/we feel overwhelmed.
I/We feel comfortable asking for help.
I/We feel satisfied with the amount of self-care we are able to practice.

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* 9. How many children (under 18) reside in your household?

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* 10. How successfully do you feel that your child(ren) will use the contents of their Superstar Sibling Box? Is there a particular item in the kit that you feel like your child will find the most useful?

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* 11. Is there anything else you'd like us to know?

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