Hemophilia Federation of America: Assisting and Advocating for the Bleeding Disorders Community

Adult/Family Registration

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Symposium Family Registration

This registration form is for an Adult & their Spouse or Adults and their Family Registration only. After clicking "Register" you will be directed to Paypal to complete your order. Your registration will be ON HOLD until you finish the Paypal payment process. If you wish to pay your Registration Fee by check please download the PDF registration form and mail both in together.

Registration Type*
- Adult & Spouse
- Family Registration
Please select if you are registering for an Adult & Spouse or a Family Registration. To register children 18 and under, please make sure to fill out all children information for each child later in THIS form. Young adults (ages 18-21) living at home with parent(s) may be included as part of the family registration.
Name*
FirstLast
Address*
Street AddressAddress Line 2CityStateZip Code
Home Phone*
Work Phone
Email
Relation to Hemophilia/Other Bleeding Disorder*
- Factor VII
- Factor IX
- Factor VIII
- Other Factor
- vonWillebrand's
- Family Member
- Friend of Family
- Carrier
- Inhibitor
- Other
Other Factor/Relationship*
Please specify other factor or relationship.
Breakout Session Choice*
- HFA Dads in Action
- HFA Focus on the Feminine
- HFA Blood Brotherhood Session
Please choose one breakout session for Saturday, April 24th.
Photo Release*
- Yes
- No
Do you authorize the use of photographs or videos for HFA use only?
Spouse Attending?*
- Yes
- No
If your spouse will be attending please select yes and fill out their information as well.
Are you registering children?*
- Yes
- No
Please make sure to fill in all information for each child in the sections below.
Are you a Board Member?*
- Yes
- No
Will you be applying for a Symposium Scholarship? (NOTE: Please download and mail in Scholarship Application form to complete application.)*
- Yes
- No
Spouse Information
Name*
FirstLast
Work Phone
Cell Phone
Email
Spouse Breakout Session Choice*
- HFA Dads in Action
- HFA Focus on the Feminine
- HFA Blood Brotherhood Session
Family Information
Number of Children*
Please enter a value between 1 and 10.
Please list the total number of children that will be attending.
Children Notes
Please list ALL medical conditions, and include ALL medications (including FACTOR), as well as any other information necessary to ensure your children’s safety. Please list specific information about all children here.
Child #1
Child #1 Name*
Child #1 Age
Please enter a value between 0 and 21.
If under 1 year, please enter months/weeks below
Child #1 Gender
- Male
- Female
Child #1 Birthdate
Child #1 Relationship to Hemophilia
- Factor VII
- Factor XI
- Factor VIII
- Other Factor
- vonWillebrand's
- Family Member
- Friend of Family
- Carrier
- Inhibitor
- Other
Child #2
Child #2 Name
FirstLast
Child #2 Age
If under 1 year, please enter months below
Child #2 Gender
- Male
- Female
Child #2 Birthdate
Child #2 Relationship to Hemophilia
- Factor VII
- Factor XI
- Factor VIII
- Other Factor
- vonWillebrand's
- Family Member
- Friend of Family
- Carrier
- Inhibitor
- Other
Child #3
Child #3 Name
FirstLast
Child #3 Age
If under 1 year, please enter months below
Child #3 Gender
- Male
- Female
Child #3 Birthdate
Child #3 Relationship to Hemophilia
- Factor VII
- Factor XI
- Factor VIII
- Other Factor
- vonWillebrand's
- Family Member
- Friend of Family
- Carrier
- Inhibitor
- Other
Child #4
Child #4 Name
Child #4 Age
If under 1 year, please enter months below
Child #4 Gender
- Male
- Female
Child # Birthdate
Child #4 Relationship to Hemophilia
- Factor VII
- Factor XI
- Factor VIII
- Other Factor
- vonWillebrand's
- Family Member
- Friend of Family
- Carrier
- Inhibitor
- Other
Child #5
Child #5
FirstLast
Child #5 Age
If under 1 year, please enter months below
Child #5 Gender
- Male
- Female
- Prefer Not to Answer
Child #5 Birthdate
Child #5 Relationship to Hemophilia
- Factor VII
- Factor XI
- Factor VIII
- Other Factor
- vonWillebrand's
- Family Member
- Friend of Family
- Carrier
- Inhibitor
- Other

Last updated: December 21, 2009

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210 7th St. SE, Suite 200 B

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Toll Free: 800.230.9797
Phone: 202.675.6984
Fax: 202.675.6983

Email: info@hemophiliafed.org

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