Where

This is an online event.

Contact

Hanna Beary
Hemophilia of Iowa
319-393-4007
h.beary@hemophiliaofiowa.org

2019 Hemophilia of Iowa Membership

HOI membership brings you information, resources and access to activities that are fun for the whole family. Your family can join other families that make up our vibrant and growing community. By becoming a member of HOI you will receive all the latest news and updates.

* Required information

Personal Information

  • Membership January 1 – December 31, 2019 Single, Family, Industry Representative, and Friends of Hemophilia of Iowa, Inc. Family includes residents in the same household with dependent children up to the age of 25. (Dependent children do not have to reside in the parent’s home if away at school or living on their own.) Example of relative would be sister, brother, grandparent, aunt, uncle and/or cousin to the person who has a bleeding disorder. Friends of Hemophilia of Iowa, Inc. are people who do not have a relative with a bleeding disorder but are support people and friends of those who do have a bleeding disorder. THE HEAD OF HOUSEHOLD SHOULD COMPLETE THE INFORMATION BELOW:

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    Best time/way to contact me:

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Association to Bleeding Disorder Community Questions:

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    What is your association to the bleeding disorders community? Check all that apply

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    If you yourself, your spouse or child have a bleeding disorder, which HTC/Hematology Clinic are you/they seen at?

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Family Membership Information:

  • What programs are you and your family interested in? (choose as all that may applies)

  • Complete the following information for every family member that is considered part of this membership (not including yourself) (Bleeding disorder Yes = someone who has a confirmed diagnosis and has a treatment plan.)

  • Do you have a bleeding disorder? If so what is the type of Bleeding Disorder:

  • Do you have a bleeding disorder? If so what type of Bleeding Disorder?

Membership Information Cont.

  • Do you have a bleeding disorder? If so what type of bleeding disorder?

  • Do you have a bleeding disorder? If so what type of bleeding disorder?

  • Do you have a bleeding disorder? If so what type of bleeding disorder?

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