Community Outreach Program November 18th 2023

Join us for dinner and discussion presented by Susan Geraghty entitled, Navigating Your Insurance. Please register by 11/11/23.

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.

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Date
Date(s) - November 18 2023 at 6:00 PM - 8:15 PM

Location
Larkspur Bistro & Bard

Category(ies)

First Name	Last Name	Date of Birth	Diagnosis

First Name	Last Name	Date of Birth	Diagnosis