Advocacy Network Interest Form

Thank you for your interest in joining the HFA Advocacy Network! We're thrilled to have you with us as we work together to amplify the voices of the bleeding disorders community. Advocacy is a powerful tool for creating positive change, and with your support, we can make an even greater impact.

Personal Information

First Name:

Last Name:

Email Address:

Phone Number:

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I agree.

Mailing Address

Mailing Address:

City:

State:

Zip Code:

Connection to Bleeding Disorders Community

Do you have a bleeding disorder?

Yes

Please specify your Bleeding Disorder Type: (check all that apply)

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

Are you a caregiver of a person with a bleeding disorder?

Yes, I'm a parent of a person with a bleeding disorder.Yes, I'm a partner/spouse of a person with a bleeding disorder.

Interest in Advocacy

Why are you interested in becoming an advocate for the bleeding disorder community?

What specific issues related to bleeding disorders are you most concerned about?

Access to TreatmentInsurance CoverageResearch FundingEducation & AwarenessLegislative AdvocacyOther(Check all the apply)

Other, please explain:

Experience and Skills

Do you have any prior experience in policy advocacy?

Yes

If Yes, please describe:

Preferred Communication and Comments

How would you prefer to receive updates and information?

EmailPhoneText Message

Please share any other information, comments, or questions you may have: