Community Outreach Program: Go Ahead, Give Hemlibra A Shot!

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Date
Date(s) - March 30 2023 at 6:30 PM - 8:30 PM

Category(ies)

Community Outreach Program

Connect with your local community members with MHA as the host for a dinner education program for the family. Program and dinner provided by event sponsor, Genentech.

For more details, see official invitation. RSVP by Monday, March 26th. Late registration WILL be accepted, but we need a minimum headcount by March 26th in order not to cancel.

March 30, 2023 Wichita KS Community Outreach Registration

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
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.
- No I do NOT consent to the use of pictures of videos.

First Name	Last Name	Date of Birth	Diagnosis

First Name	Last Name	Date of Birth	Diagnosis