Men’s Retreat 2023 – Midwest Hemophilia

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

Address*

Street Address Address Line 2 City State ZIP Code

PLEASE PROVIDE THE 4-DIGIT ZIP EXTENSION.*

If you do not know your 4-digit zip extension, visit https://tools.usps.com/zip-code-lookup.htm?byaddress

Phone*

Email

Chapter Affiliation:*

Gateway Hemophilia Association
Mid West Hemophilia Association

What kind of insurance do you have? (Your answer is optional. Knowing this information allows us to be informed and better advocates for our community.)

Medicaid - Medicaid is a medical assistance program administered by the state and funded through a state-federal partnership.
Medicare - Medicare is the federal health insurance program for people who are 65 or older, and some people under the age of 65 who are disabled or suffer from End-Stage Renal Disease (sometimes referred to as ESRD).
Marketplace - Marketplaces are a “one-stop-shop” for individuals and small business owners to compare and purchase health plans.
Employer Plans - Employer sponsored insurance, often referred to as a job-based plan or group health plan, is health insurance provided by an employer for their employees and in some cases, their families
Individual Insurance Plan - An individual health insurance policy is one that is not provided through an employer and covers a single person or multiple people (families, mother and dependent children, husband and wife, etc.).
Tricare - a health insurance benefit program available to active duty, reservists, and retired members of the United States uniformed services, their families and survivors.
Unknown
Prefer not to answer

Type of Community Member ?*

Person with a bleeding disorder
Family Member of a person with a bleeding disorder
HTC Staff
Specialty Pharmacy Company
Pharmaceutical Company
Other

Are you employed by a Specialty Pharmacy or Pharmaceutical Company that serves bleeding disorder patients?*

Yes
No

Please specify they company:*

Please Indicate Type of Bleeding Disorder (if you are a consumer or caregiver):*

Hemophilia
VWD
Platelet Disorder
Other Bleeding Disorder
N/A
Other

Please specify Other Bleeding disorder:

List any dietary restrictions (vegetarian, specific allergies, etc.)?*

If None please state "None" or "N/A"

Do you authorize the use of photographs or videos of you for GHA or MHA use?*

Yes
No

If available, please select the hotel accommodation you prefer*

King Bed
2 Doubles
Handicapped-Accessible Room
I am not requesting a hotel room

Please let us know the name of the person if you are willing to share a room.

Any other special accommodations or needs?

Do you plan to attend Friday night's reception/pizza dinner from 6:30 - 8:00 p.m.?*

Yes
No

We can assist with a gas card at the end of the retreat if requested. Please mark if you would like a gas card to help with your travel.*

Yes
No

I acknowledge that I am expected to attend educational programming on Saturday and Sunday during Men's Retreat. If I am unable to attend Men's Retreat, I will immediately let an executive director know. If I fail to notify, I understand I may be charged for the hotel room and/or jeopardize attendance at future chapter events.*

I agree.

PLEASE NOTE: The appropriate registration fee should be submitted as part of your registration, unless you are requesting a waiver. The non-refundable registration fee covers your hotel room, conference meals, and conference materials.*

Total

$0.00

Mens Retreat 2023