Newsletter and Membership

GHA membership brings you information, resources and access to activities that are fun for the whole family. Join other individuals that make up our vibrant and growing community.

If you’d like to join GHA, complete the free application form below. The form is processed through a secure server, so your personal information is safe. Click here for GHA’s Privacy Notice.

Gateway Hemophilia Association
4976 Eichelberger Street, St. Louis, MO 63109

Phone: 314.482.5973 E-mail: info@gatewayhemophilia.org

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone
Email*
Type of Community Member (Please check all that apply)*
If other, please list
Type of Bleeding Disorder*
If other bleeding disorder, please list
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer
Would you like to list a family member?*
- Yes
- No
Name of additional member in your house
First Last
Date of Birth
MM slash DD slash YYYY
Phone
Email
Type of Community Member (Please check all that apply)
If other, please list
Type of Bleeding Disorder
If other bleeding disorder, please list
Would you like to list another family member?*
- Yes
- No
Name of additional member in your house
First Last
Date of Birth
MM slash DD slash YYYY
Type of Community Member (Please check all that apply)
If other, please list
Type of Bleeding Disorder
If other bleeding disorder, please list
Would you like to list a third family member?
- Yes
- No
Name of additional member in your house
First Last
Date of Birth
MM slash DD slash YYYY
Type of Community Member (Please check all that apply)
If other, please list
Type of Bleeding Disorder
If other bleeding disorder, please list
Would you like to list a fourth family member?
- Yes
- No
Name of additional member in your house
First Last
Date of Birth
MM slash DD slash YYYY
Type of Bleeding Disorder
If other bleeding disorder, please list
Additional person in your household & DOB (if applicable)
Name of your Bleeding Disorder Doctor (hematologist)
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.)
Primary Language Spoken*
What is your preferred way to receive communication from us? (Text, Email, Phone Call, etc.)
Would you like to receive your newsletter via email?
- Yes
- No