Community Outreach Program: Wichita Kansas Area

Open to all ages and any bleeding disorder diagnosis (VWD, Hemophilia A or Hemophilia B). You’re invited to a Common Factors Educational Program with Jesse S., Gettin’ In the Game Athlete and Patient Advocate. Dinner and golf activity provided.

Space is limited to the first 30 registrants!

Thank you to our sponsors:

October 6th 2022 Wichita Kansas 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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Date
Date(s) - October 6 2022 at 6:00 PM - 8:00 PM

Location
Golf-In

Category(ies)

Community Outreach Program

First Name	Last Name	Date of Birth	Diagnosis

First Name	Last Name	Date of Birth	Diagnosis