Females and Bleeding (FAB) Conference 2021

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Example: (212) 555-1212

Date of Birth*

Type of Bleeding disorder:

Type of Community Memeber*

Person with a bleeding disorder
Parent/Guardian of a person with a bleeding disorder
Carrier of bleeding disorder
Spouse of a person with a bleeding disorder
HTC Staff
Not Applicable

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Relation*

How Will you be attending?*

In Person
On-ling via Zoom

Are you attending the reception at 6:00pm on Friday, October 8th?

Yes
No

Any Dietary Needs:

Your health and safety are at the forefront of our minds regarding this program. Prior to the Covid-19 pandemic, we had asked you to share a room with another member of your community but with current CDC guidelines and social distancing, we no longer feel that is in your best interest. We have expanded our room pool to allow for private rooms but do ask that members who reside in the same household share a room to keep space open for as many registrants as possible. Please indicate if you are in need of a private room or if there is a household member you will be sharing with. Thank you for your patience and understanding as we navigate safety protocols for in person and/or hybrid events. Name of person you would share a room with:

What 2-3 things do you hope to get out of this retreat?*

Registration Fee*

Price: