Hemophilia Federation of America Annual Meeting & Symposium

The Peabody Hotel • Little Rock, Arkansas
May 2-3, 2008

ADULT/FAMILY ONLINE REGISTRATION FORM

Welcome to the HFA Symposium 2008 Adult/Family Online Registration Form.

This form is intended to be completed and submitted online. If you register online, you MUST also pay online using PayPal.

If you would rather not pay online, download, print and mail your completed form(s) and payment to HFA.

Please follow instructions carefully to ensure your registration is properly submitted to us. All parts preceded by a "*" are required.

Registration Information

*Type of Registration

*Do you authorize the use of photographs or video that include yourself and/or your family members for HFA's use only? Yes No

Self

*Gender

*First Name

Middle Initial

*Last Name

*Address

*City

*State

*Zip

*Home Phone

Work Phone

Cell Phone

*Email Address

Relation to Hemophilia/Other Bleeding Disorder

Do you have an Inhibitor? Yes No

*Breakout Session Choice for Saturday, May 3

Spouse

If you are completing an "Individual" or "Self and Children" registration, you can skip this section.

Gender

First Name

Last Name

Work Phone

Cell Phone

Email Address

Spouse's Relation to Hemophilia/Other Bleeding Disorder

Does your spouse have an Inhibitor? Yes No

Breakout Session Choice for Saturday, May 3

Child/Teen/Young Adult

If you are completing an "Individual" or "Self and Spouse" registration, you can skip this section.

Children/teens under age 18 must be accompanied by a responsible adult. Young adults (ages 18-21) living at home with parent(s) may be included as part of the family registration.

List the full names of all children/teens/young adults you are registering:

Hemophilia Federation of America Annual Meeting & Symposium

The Peabody Hotel • Little Rock, Arkansas May 2-3, 2008

ADULT/FAMILY ONLINE REGISTRATION FORM

The Peabody Hotel • Little Rock, Arkansas
May 2-3, 2008