HFA Young Adult Advocacy Summit Registration and Policy & Government Relations Internship Application
Basic Information
First and Last Name must be as printed on your government ID and/or passport.
First Name:
Last Name:
Birthdate:
Gender:
Male
Female
Non-Binary
Prefer not to answer
Other
To improve diversity and inclusion efforts at the Hemophilia Federation of America, please select the option(s) that best describes your race and/or ethnicity:
(Check all that apply)
E
Hispanic
White, non-Hispanic
Black or African American
American Indian and Alaska Native
Asian
Middle Eastern and North African
Native Hawaiian and Other Pacific Islander
Other Race and Ethnicity
Prefer Not to Say
Are you currently employed with a home care, specialty pharmacy, or product manufacturer?
Yes
No
Please share the name of your employer:
Contact Information
Street Address:
City:
State:
Please select...
AA
AE
AK
AL
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code:
Email:
Cell Phone:
* Best number to reach you while traveling to Summit
Home Phone:
What major airport is closest to you?
Emergency Contact
Emergency Contact Name:
Emergency Contact Phone:
Relationship to you:
Please select...
Spouse/Partner
Parent
Child
Other
About You
Do you have a bleeding disorder?
Yes
No
(Check all that apply)
B
VIII (8)
IX (9)
von Willebrand (vWD)
vWD Type 1
vWD Type 2
vWD Type 3
I (fibrinogen)
II (prothrombin)
V (5)
VII (7)
X (10)
XI (11)
XIII (13)
Platelet Disorder
Other
Do you have a diagnosed chronic medical condition?
Yes
No
Please provide more information on your diagnosed chronic medical condition:
Do you require any special accommodations to participate in the Summit?
Yes
No
Please provide more information on your request for special accommodations:
Do you have any dietary restrictions? If so, please provide details:
Interest in the Young Adult Advocacy Summit
Briefly share why you would like to attend and what you hope to gain from participating in HFA’s Young Adults Advocacy Summit:
Interest in the Policy & Government Relations Internship
Are you interested in also being considered for the Policy & Government Relations Internship?
Yes
No
Please upload your cover letter or letter of interest: (pdf or Word only)
Please upload your r
é
sum
é
: (pdf or Word only)
Please upload a letter of recommendation: (pdf or Word only)