Community Outreach Program: Joplin

Hemlibra Ambassador Fireside Chat

Join your MHA community for a dinner education program where you will hear Patient Ambassador, Devon, share his personal bleeding disorder story.

This branded program is intended for Hemophilia A Patients (with or without inhibitors) and their family.

Registration ends October 13th.

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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Date
Date(s) - October 18 2022 at 6:00 PM - 8:00 PM

Location
Mythos

Category(ies)

First Name	Last Name	Date of Birth	Diagnosis

First Name	Last Name	Date of Birth	Diagnosis