Community Outreach Program: Hello Talk

Open to all bleeding disorders, come learn, share & interact at Takeda’s Hello Talk: Beyond Bleeding Disorders–Recipe for A Healthy Lifestyle. A healthy lifestyle can really move you! Use healthy eating habits to fuel your body and improve your emotional well-being. Get tips on how to fuel smart when you are out or on the run. Presented by Kevin Ellebrecht, Takeda Community Education Specialist.

RSVP by Friday, July 19th!

Community Outreach Program July 25 2024

Adults Attending:*
Click the PLUS sign next to the box to add more. Diagnosis examples: Hemophilia A, Hemophilia B, von Willibrands, Carrier, Other, N/A
First Name Last Name Date of Birth Diagnosis
Kids attending:
Click the PLUS sign next to the box to add more. Diagnosis examples: Hemophilia A, Hemophilia B, von Willibrands, Carrier, Other, N/A
First Name Last Name Date of Birth Diagnosis
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Are you employed by a specialty pharmacy or product manufacturer?*
- No, I am not employed by a specialty or product manufacturer. .
- Yes, I am employed by a specialty pharmacy or product manufacturer.
Photo Consent Opt Out -From time to time, the Midwest Hemophilia Association (MHA) will want to use pictures and/or videos from our events to promote bleeding disorder programs and MHA's activities. Please check the box below if you would NOT like to grant permission to be able to use your image or those who have registered for that purpose.
- Yes I DO consent to the use of pictures of videos.
- No I do NOT consent to the use of pictures of videos.
Have ever experienced an inhibitor?
- Yes, I/we have or have had an inhibitor.
- No, I/we have not had an inhibitor.

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Date
Date(s) - July 25 2024 at 6:00 PM - 8:30 PM

Location
Metropolitan Grill

Category(ies)

First Name	Last Name	Date of Birth	Diagnosis

First Name	Last Name	Date of Birth	Diagnosis