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FEW
FEW
FEW Registration
By continuing, you agree that you are attending the FEW as a consumer.
*
I Agree
Name of person completing this form
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
*
Is this your first FEW?
*
Yes
No
PLEASE NOTE:
The appropriate registration fee should be submitted as part of your registration, unless you are requesting a waiver. Please email info@gatewayhemophilia.org if you know if you are requesting your registration fee be waived.
Product Name
Option
*
$30 Individual
$40 Family (adult(s) + children)
Asking for a waiver this year
Attending Virtually
Number of Adults
*
1
2
3
Name of Adult
*
First
Last
Gender
*
Male
Female
You family's relation to Hemophilia/Other Bleeding Disorder: (check all that apply)
*
Factor VIII
Factor IX
Factor X
Von Willebrand Disease
Platelet Disorder
Inhibitor
Carrier
Spouse
Parent / Caregiver
Other
Grandparent
Other (Please Specify)
Are you employed by a Specialty Pharmacy or Pharmaceutical Company that serves bleeding disorder patients? GHA will not cover your hotel if you work for one of our industry partners.
*
Yes
No
If yes, which company?
List any dietary restrictions for adult #1 (vegetarian, specific allergies, etc.)?
Adult #2
Name
First
Last
Email
Gender
Male
Female
Relation to Hemophilia/Other Bleeding Disorder (check all that apply)
Factor VIII
Factor IX
von Willebrand's
Inhibitor
Carrier
Spouse
Parent / Caregiver
Other
Grandparent
GHA Board of Directors
Other (Please Specify)
Is adult #2 employed by a Specialty Pharmacy or Pharmaceutical Company that serves bleeding disorder patients?
No
Yes
If yes, which company?
Does adult #2 have any dietary restrictions?
Adult #3
Name
First
Last
Gender
Male
Female
Does adult #3 have any dietary restrictions?
Do you authorize the use of photographs or videos of you and your family members for GHA use?
*
Yes
No
Number of Children/Teens attending FEW between the ages 0-18. *Please note, we include them in our meal count. If your child will not attend FEW, please don't include them.
*
0
1
2
3
4
5
Child #1
Name
First
Last
Child #1 Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Male
Female
Child's relation to Bleeding Disorder: (check all that apply)
Factor VIII
Factor IX
von Willebrand's
Inhibitor
Carrier
Sibling
Other
Other (Please specify)
GHA may not dispense medication of any kind. Please list ALL medical conditions, and include ALL medications (including FACTOR), as well as any other information necessary to ensure your child's safety.
Please list any food allergies or special diet needs:
Child #2 (if applicable)
Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Male
Female
Child #2's relation to Bleeding Disorders: (check all that apply)
Factor VIII
Factor IX
von Willebrand's
Inhibitor
Carrier
Sibling
Other (Please specify)
GHA may not dispense medication of any kind. Please list ALL medical conditions, and include ALL medications (including FACTOR), as well as any other information necessary to ensure your child's safety.
Please list any food allergies or special diet needs:
Child #3 (if applicable)
Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Male
Female
Child # 3's relation to Bleeding Disorders: (check all that apply)
Factor VIII
Factor IX
von Willebrand's
Inhibitor
Carrier
Sibling
Other (Please specify)
GHA may not dispense medication of any kind. Please list ALL medical conditions, and include ALL medications (including FACTOR), as well as any other information necessary to ensure your child's safety.
Please list any food allergies or special diet needs:
Child #4 (if applicable)
Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Male
Female
Relation to Hemophilia/Other Bleeding Disorder: (check all that apply)
Factor VIII
Factor IX
von Willebrand's
Inhibitor
Carrier
Sibling
Other (Please specify)
GHA may not dispense medication of any kind. Please list ALL medical conditions, and include ALL medications (including FACTOR), as well as any other information necessary to ensure your child's safety.
Please list any food allergies or special diet needs:
By submitting this application, you, the parent/legal guardian, hereby consents to their child participating in the activities of the Gateway Hemophilia Association's Youth program at its FEW event. You, the parent/legal guardian, does hereby release, hold harmless and agree to indemnify the Gateway Hemophilia Association from any and all liability resulting from the participation of said child in the activities sponsored and conducted by the Gateway Hemophilia Association’s Youth Programs.
*
I Agree
I am not registering a child at FEW
General Comments
What kind of insurance do you have? (Your answer is optional. Knowing this information allows us to be informed and better advocates for our community.)
Medicaid - Medicaid is a medical assistance program administered by the state and funded through a state-federal partnership.
Medicare - Medicare is the federal health insurance program for people who are 65 or older, and some people under the age of 65 who are disabled or suffer from End-Stage Renal Disease (sometimes referred to as ESRD).
Marketplace - Marketplaces are a “one-stop-shop” for individuals and small business owners to compare and purchase health plans.
Employer Plans - Employer sponsored insurance, often referred to as a job-based plan or group health plan, is health insurance provided by an employer for their employees and in some cases, their families
Individual Insurance Plan - An individual health insurance policy is one that is not provided through an employer and covers a single person or multiple people (families, mother and dependent children, husband and wife, etc.).
Tricare - a health insurance benefit program available to active duty, reservists, and retired members of the United States uniformed services, their families and survivors.
Unknown
Please select the hotel accommodation you prefer:
*
King Bed
2 Queen Beds
Handicapped-Accessible Room
I am not requesting a hotel room
Any other special accommodations or needs?
If you do not currently self-infuse, do you want to sign up to practice a peripheral infusion at FEW? (There are a limited number of spots, we will have nurses to assist between 8:00 - 10:00 a.m. Saturday, July 11 and a designated time will be assigned for you)
*
Yes
No
Which of the following events do you plan to attend?
*
Friday night "Meet Your Board Reception" 6:30-8:00 p.m.
Friday night "Bombardier Blood Movie" 8:15 - 9:00 p.m.
Saturday programming 9:30 - 5:00 p.m.
Saturday night Awards Dinner 6:00 - 7:30 p.m.
A Saturday night room will be reserved, unless you state otherwise. We are offering Friday night rooms to our attendees traveling more than 100 miles (one way) to attend and to first time attendees, (those who have never attended a GHA FEW).
*
First time attendee, requesting a Friday night room
Driving more than 100 miles one way to attend FEW, requesting a Friday night room
I have a camper attending between the ages of 7-17 and I'm requesting a Friday night room
I am only requesting a Saturday night hotel room
I am not requesting a hotel room for Friday or Saturday night
I am a GHA Board member, requesting a Friday night room
Total
$0.00