Community Outreach Program: Hemlibra Ambassador Fireside Chat

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Date
Date(s) - August 17 2021 at 6:00 PM - 8:00 PM

Location
Newport Grill

Category(ies)

Community Outreach Program

August 24, 2021

6:00-8:00pm

Register by August 12!

FLYER ->

Aug 24th 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.

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